School of Nursing
Online Journal

E-cigarettes and E-liquids: An effective tool to quit smoking

Kylie Hough

Introduction

The goal of this paper is to investigate and critically discuss how the use of e-cigarettes help in providing a pathway away from the barriers affecting smokers and their ability to quit smoking traditional tobacco products. Firstly this paper will briefly discuss New Zealand smoking statistics and the clinical health issues of the effects of traditional tobacco use in comparison to e-cigarettes. Secondly, it will show how using the PECOT (Whitehead, 2013) model, I was able to refine my question more specifically to New Zealand. Following this I will then critically discuss evidence-based literature; on the two main barriers, smokers face in how to quit smoking and/or reduce the amount of tobacco they smoke using e-cigarettes. Included in this section will be an overview of a New Zealand retailers suggested pathway in how to transition a smoker from traditional tobacco products to e-cigarettes and the process of weaning off nicotine. Recommendations with rational will proceed the evidence-based literature.

Clinical issue

The Ministry of Health (MoH) states that tobacco use is the leading cause of preventable diseases and deaths in New Zealand, responsible for approximately 4,300 to 4,700 deaths per year (Ministry of Health, 2018). Although the prevalence of smoking in New Zealand has declined, there are still more than 650,000 New Zealand adults who smoke on a regular basis (18% of the adult population) (Ministry of Health, 2017). The Ministry of Health reports that Māori and Pacifica people are more likely to smoke than other ethnicities in New Zealand (Ministry of Health, 2018).

Cigarettes contain over 70 harmful chemicals, of which 10 are known to cause cancer (Cancer Society, 2018b). One of the most abundant chemicals found in a cigarette is nicotine, a highly addictive chemical that can be used as an insecticide, and has been proven to be as addictive as cocaine or heroin (Cancer Society, 2018b). Some of the other chemicals include butane, methanol, benzene, acetone, ammonia, tar, carbon monoxide and arsenic. Many of the chemicals contained in a cigarette can have effects on the body to the deepest level, damaging not only the vital organs but also the smokers DNA (Cancer Society, 2018b).

The Cancer Society (2018b), explains that second-hand smoke is also very dangerous to people, as it is a mix of two kinds of smoke; the smoke breathed out by the smoker and the smoke from the burning tip. This makes second-hand smoke four times more toxic than the smoke breathed out from the smoker (Cancer Society, 2018b). Second hand smoke has been proven to be more toxic especially to young children who often have no choice to regards to exposure of second-hand smoke (Cancer Society, 2018a).

The MoH (2016b) states that in comparison to traditional tobacco products, although not completely harmless, e-cigarettes are significantly less harmful than tobacco. E-cigarettes vaporise a solution that the user then inhales, they do not burn or use tobacco leaves (World Health Organisation, 2015; Knight-West & Bullen, 2016). Toxicants are still found in e-cigarette vapour, including some cancer-causing agents, but at much lower levels than in a traditional cigarette – because of this, smokers who switch to e-cigarettes are likely to reduce the health risks not only for themselves, but also for those around them (Dockrell, 2018; Ministry of Health, 2016b; World Health Organisation, 2015). E-cigarettes do not contain tar or carbon monoxide, which are two of the most harmful elements in tobacco smoke (Dockrell, 2018).

With the health benefits of fewer chemicals and the reduced risks of second-hand smoking from e-cigarettes, the focus of this paper shifts to how e-cigarettes can help in providing a pathway away from the barriers affecting smokers aged 18+, and their ability to quit smoking traditional tobacco products.

PECOT – formulation of a research question

There are two reasons why I chose to research how e-cigarettes help smokers to quit traditional tobacco products. Firstly, because smoking tobacco is one of the main hazardous, modifiable risks to health and health outcomes in New Zealand, particularly for cardiovascular and respiratory disease and many cancers (McRobbie, 2009; Ministry of Health, 2017). And secondly, due to Ministry of Health’s goal to New Zealand being smoke-free by 2025, I decided to take the opportunity to advance my personal clinical knowledge of the use of e-cigarettes using evidence-based research (Ministry of Health, 2018).

Using PECOT (Whitehead, 2013), I was able to formulate the following searchable research question - “With the Ministry of Health’s proposal of a smoke-free New Zealand by 2025, how does the use of e-cigarettes help in providing a pathway away from the barriers affecting smokers aged 18+ and their ability to quit smoking traditional tobacco products?

Review of evidence-based literature

Bullen, et al. (2013) and the MoH (2016) describe an e-cigarette as a battery powered electronic device that heats a solution or “e-liquid” often containing a solution of propylene glycol and/or glycerine (that may contain nicotine) that the user can inhale or “vape”. McRobbie (2009) and Barbeau, Burda and Siegel (2013) state that the three main barriers smokers face when attempting smoking cessation which e-cigarettes can assist with are the nicotine withdrawal/craving and physical action, as well as the bio-behavioural aspect of smoking. Barbeau, Burda and Siegel (2013), also explain that nicotine is an internationally recognised, addictive, psychoactive drug, which can result in withdrawal symptoms such as irritability and anxiety, which can make quitting very difficult. The MoH (2016b) expresses that New Zealand law prohibits people under the age of eighteen from purchasing e-cigarettes, cartridges and traditional tobacco products. Knight-West and Bullen, (2016) suggest that e-cigarettes enable the smoker to achieve smoking cessation by a process of weaning away from the nicotine addiction. This is achieved through fighting the physical dependence of the drug, using small amounts of nicotine, as required. Currently, New Zealand laws mean the retailers can legally sell e-cigarettes that do not resemble a traditional tobacco cigarette, as well as e-liquids not containing nicotine, to people over the age of eighteen. However, there are no laws to stop people buying e-cigarettes or e-liquids containing nicotine online (Ministry of Health, 2016b; Truman, Glover, & Fraser, 2018). E-cigarette liquids containing nicotine, deliver nicotine as rapidly to the brain as a traditional cigarette, although e-cigarettes are unlike traditional tobacco in a number of ways (Knight-West & Bullen, 2016). E-cigarettes do not use tobacco, but also more importantly, rather than producing smoke they produce a vapour that the user inhales, otherwise known as “vaping” (Dockrell, 2018; Knight-West & Bullen, 2016; Ministry of Health, 2016b).

When a person wants to give up smoking by means of e-cigarettes, the smoker does not have to completely stop using nicotine and they do not have to use the existing Nicotine Replacement Therapy (NRT) available in New Zealand if they do not wish to do so. Truman, Glover and Fraser (2018), explain that e-cigarettes operate with nicotine cartridges or liquids that allow the smoker to customize their nicotine levels from strong to none. As well as the option to alter nicotine levels, the smoker can choose from an assortment of cartridges or liquid flavours and an extensive variety of e-cigarette models (Knight-West & Bullen, 2016; Barbeau, Burda & Siegel, 2013). Truman, Glover and Fraser (2018) state that because of these options, tobacco smokers transiting to e-cigarettes can have complete control of the desired strength and taste of e-liquids that best suits their needs. Dockrell (2018) suggests that it is important that e-liquids are packaged and labelled correctly and clearly, providing information, such as ingredient, so consumers can make informed choices. Vapor Cigarettes (n.d.), a New Zealand retailer of e-cigarettes, expressed that to completely understand how e-cigarettes help the smoker, it is critical that users recognize the method of how to achieve smoking cessation. Vapor Cigarettes (n.d.) recommends that when transiting to an e-cigarette from tobacco, the user should use an e-liquid of high strength. Heavier tobacco smokers may require a strong strength nicotine solution, whereas social smokers may go for a lighter strength range liquid. Truman, Glover, & Fraser (2018), suggest that many smokers require a transition period switching from tobacco to e-cigarettes, and therefore often smoke both for a small amount of time.

Vapor Cigarettes (n.d.) suggested that as time progresses, the smoker can reduce the nicotine levels of their e-cigarette from the higher strength to medium strength. It is important that the smoker remains focused and takes their time, as dropping nicotine levels may cause them to feel unsettled. Low strength nicotine e-liquids means that the smoker is only one step away from smoking cessation. Once the smoker has advanced to the lower levels of nicotine, the smoker is encouraged to lessen the dependence of the e-cigarette – possibly leaving the e-cigarette at home when visiting friends, or leaving it in the car while at work. The rationale for this is that the e-cigarette is not easily reached but it is close enough that if the urge become too much to restrain it is easily available. By doing this, the smoker is introduced to the idea of being a non-smoker.  Vapor Cigarettes (n.d.), suggests the final step is to drop to a zero nicotine solution. The smoker may experience feelings of irritability for some days following this step as their body adjusts to dropping levels of nicotine in their system. By this stage it is believed that the smoker will have figured out how to utilize their e-cigarette as a smoking tool, for therapeutic use, having overcome the moral problem of the nicotine addiction. Truman, Glover and Fraser (2018), recommend that in the event that the smoker feels the need for a cigarette, they are able to return to smoke a zero nicotine e-cigarette – so it is important that the now ex-smoker still has access to their e-cigarette.   E-cigarettes also address the bio-behavioural factors associated with smoking (Barbeau, Burda & Siegel, 2013; Knight-West & Bullen, 2016). In a study conducted by Barbeau, Burda & Siegel (2013), the finding from the participants that were interviewed, exposed that the learnt hand to mouth behaviour associated with the action of smoking, is not addressed by existing other smoking cessation products like NRT available in New Zealand. Participants who were involved in the qualitative study expressed by way of focus groups, that they felt e-cigarette “vaping” mimicked the action of smoking a real cigarette. This evidence is backed by another qualitative online study conducted in New Zealand by Truman, Glover, & Fraser (2018). This information addressed the oral fixation of smoking combined with the familiarity of inhaling, perceiving the feeling of smoke hitting the back of the throat and observing the vapor haziness on exhaling (Barbeau, Burda & Siegel, 2013). Participants who were involved in this study also explained that these particular elements enabled them to adapt e-cigarettes into their accustomed smoking routine (Barbeau, Burda & Siegel, 2013). The MoH (2016a) believe it is important for health professionals to combine behavioural support with stop smoking medicine for the greatest chance for smoking cessation, particularly when working with smokers who are Māori.

Bullen, et al. (2013) conducted a study in New Zealand on the effectiveness of using e-cigarettes as a means of smoking cessation. The results showed that e-cigarettes are seemingly effective in aiding smoking cessation, but suggest more evidence is needed to establish the overall benefits and harms in the long term use to individuals and those around them (Ministry of Health, 2016b). The MoH (2016b) indicates that there is significant evidence to support the research finding that e-cigarettes present fewer health risks to smokers who switch completely from tobacco smoking. Although, it is critical to acknowledge that for smokers using e-cigarettes and e-liquids containing nicotine, even in small doses, it is still harmful to their health.

Li, Bullen, Newcombe, Walker and Walton (2013) found in a New Zealand based study that younger smokers are more likely to purchase an e-cigarette as a cessation product, compared to people 45 years of age or older. The study suggested that the older group had less knowledge about e-cigarettes and voiced concerns about their safety and cessation efficacy.

Recommendations with rationale

E-cigarettes are up to 95% better than smoking traditional tobacco products and can be used as a helpful, harm-reduction tool (Barbeau, Burda & Siegel, 2013; Quitline, 2017). It is important as health professionals that we ensure people wanting to use e-cigarettes as a means of smoking cessation, understand that the health risks associated long-term are still unknown – all that is known is the health risk of vaping is likely to be less than smoking traditional tobacco products (Ministry of Health, 2016b; Quitline, 2017).

All smokers, regardless of their method of cessation, should be supported in their smoking cessation attempt. Quitline and local face-to-face stop-smoking services should be utilized for a greater chance of smoking cessation (Ministry of Health, 2016a; Quitline, 2017). With vaping becoming more popular there are growing community online support groups (Barbeau, Burda & Siegel, 2013; Truman, Glover, & Fraser, 2018). Many of these support groups are found through searching in social media mediums such as Facebook. These groups give people a chance to ask questions and share knowledge with fellow e-cigarette users, in a safe, supportive environment, to aid their smoking cessation attempt. Health professionals may want to research which online forums are genuinely being used for the purpose of supporting smoking cessation, as there are many that are used to support the hobbyist trend referred to as “vaping nation” (NZ Vapor, 2017). E-cigarettes can be described as a smoking cessation tool, because the user can alter the levels of nicotine they are being exposed too – addressing any withdrawal symptoms that may occur when trying to give up smoking (Berg, Barr, Stratton, Escoffery, & Kegler, 2014). By smoking e-cigarettes, the user is also inhibiting the health impacts of exposure to second-hand smoke to their family, friends and work colleagues, as vapour contains fewer chemicals than smoke from traditional tobacco products. It should be noted that e-cigarettes and e-liquids should still be kept out of reach of those under 18 years of age.

Knight-West & Bullen (2016) suggest that healthcare providers should have an understanding of the use of e-cigarettes as a smoking cessation tool, to be able to provide smokers accurate and relevant information when asked to provide information on e-cigarettes. Conventional NRTs do not address the behavioural and biochemical components of traditional tobacco products that e-cigarettes can (Barbeau, Burda & Siegel, 2013; Berg, Barr, Stratton, Escoffery, & Kegler, 2014). If health practitioners have a greater understanding of the behavioural and physical elements of smoking, rather than just treating the smoking addition as a pharmacological addiction, they can support the smoker in a greater chance of smoking cessation, providing a more holistic health approach.

The financial burden of smoking is becoming a rising issue with tobacco tax increases. From January 1, 2018 the tobacco tax was increased to eighty-three cents per cigarette, with GST levied on top of that (Spencer, 2017). Under the National Party, the previous NZ government, the tobacco tax policy was set to increase per annum by ten per cent, plus Consumer Price Index (CPI) on 1 January 2019 and again on 1 January 2020 (Spencer, 2017). Nicotine patches and gum can be bought at a subsidised rate, but if the smoker wants to purchase e-cigarette liquid containing nicotine, it must be brought from overseas (Jones, 2017). Overall e-cigarettes and nicotine-free e-liquids are cheaper in New Zealand, whereas imported e-liquids containing nicotine have high tobacco tax rates (Truman, Glover, & Fraser, 2018). E-cigarettes are not subsidised in New Zealand; it is important that consumers are aware of this so if they want to quit smoking they can ensure they have the budget to cover the costs, although the overhead costs of e-cigarettes are greater than tobacco, it is likely to be more cost-effective long-term (Hāpai Te Hauora, 2018). It is important that e-cigarettes and e-liquids remain illegal to under 18-year-olds as it mimics the action of smoking (Li, et al. 2013). This is a means of harm-reduction – due to the fears that vaping could encourage young New Zealanders to start smoking (Plumb, 2017).

It is important that e-liquids available to purchase in New Zealand be packaged and labelled correctly. The United Kingdom has strict regulations in relation to the sale of e-liquids products, which have to meet quality and safety standards before being able to be sold to the public (Dockrell, 2018). New Zealand could adopt these regulations, in order to set national standards in regards to the sale of e-liquids. Dockrell (2018) states it is important that consumers be provided with information such as ingredients and nicotine percentage contained within e-liquids, to best make an informed choice that suits their need.

Recommendations; Application of the Treaty of Waitangi

It is important to consider the three principles of the Treaty of Waitangi / Te Tiriti o Waitangi when trying to achieve a smoke-free New Zealand. Māori and Pacifica people are more likely to smoke than other ethnicities in New Zealand (Ministry of Health, 2018). As health professionals, we should want the best for all health consumers and in order to do this, it is important to understand disparities of some ethnicities and cultures to strive towards equal outcomes for all peoples of New Zealand. Incorporating the principles of the Treaty of Waitangi / Te Tiriti o Waitangi into health care encompasses cultural concepts including language, values and norms that in turn are likely to lead to greater response and behavioural changes with Māori peoples (Muriwai & Glover, 2016; Gifford, Parata, & Thomson, 2010). Partnership allows for health professionals to work together with iwi, hapu and whānau to develop programs and strategies aimed at Māori health advances. Participation allows and encourages Māori to be involved at all levels of the health and disability sector; this includes decision-making, devising, evolution and delivery of health and disability services. Protection encompasses the responsibility of the Government to warrant that Māori have access to the same level of health services as non-Māori, in addition to safeguarding Māori cultural practices, values and concepts. It is important to recognise that when working with Māori and Pacific peoples that children are often the key to making changes within households – children are a large motivator for adults to quit/cut back on smoking due to a whanau focus, as the unwanted repercussion of second-hand smoke health issues for the pepe, tamariki and mokopuna of the whanau (Gifford, Parata, & Thomson, 2010). Hāpai Te Hauora (2018) believes that although further evidence is needed on the long-term effects, e-cigarettes have the potential to contribute towards the Smoke-free 2025 goal and bridge inequities in tobacco consumption between Māori and non-Māori.

Conclusion

There are many questions that are still unanswered around the use of e-cigarettes. It is important to recognise that due to the variety of e-cigarette products, it is challenging to compile sound evidence and so there is limited evidence on e-cigarettes in their long-term effectiveness and safety. Using e-cigarettes as a substitute to smoking traditional tobacco products has the potential to save many lives and reduce the rates of smoking-related morbidity. Health professionals need to have an understanding of e-cigarettes and how they work due, to the increasing numbers of smokers using e-cigarettes as a means of smoking cessation. The most positive known outcome of e-cigarettes is that there are thousands of New Zealand smokers who have changed from known harmful tobacco smoking to vaping – vaping is a healthier alternative to smoking. With the estimated number of 650,000 New Zealanders who smoke, it is vital that health providers and the New Zealand Government consider funding e-cigarettes as a pathway to smoking cessation with the over pinning aim of the country being smoke-free by 2025 – a goal that will save thousands of Kiwi lives.

Acknowledgement

Raeleen Thompson, Lecturer at Otago Polytechnic, New Zealand, for additional support.

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