Up in Smoke

Examining the Draw of E-Cigarettes

By Tara Hulen

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E-cigarettes offer a nicotine fix without the toxic smoke of traditional cigarettes, but are they really a healthier alternative to smoking?

Cherie wants to quit smoking—again. As with a lot of former ex-smokers, this busy Birmingham businesswoman found that stress triggered a relapse. But she doesn’t yet feel ready to give quitting another try, so, in the meantime, she has chosen what she sees as a healthier option: electronic cigarettes.

E-cigarettes, as they are called, are becoming a popular intermediary step for smokers looking to gradually kick the habit—and for those, like Cherie, searching for a less toxic, less offensive substitute in the interim. The basic e-cigarette design has a tan mouthpiece designed to look like a cigarette’s filter and an LED light on the tip that can glow when active. When a smoker breathes in, a battery-powered internal atomizer creates a water vapor that draws nicotine into the mouth from a replaceable cartridge.

No Consequences?

E-cigarettes are designed to deliver a nicotine fix without the cancer-causing tar, various chemicals, and smelly, toxic smoke that come with traditional tobacco cigarettes. Although nicotine is certainly highly addictive and constricts blood vessels, among other effects, it is not considered a major health threat to otherwise healthy people. (See “What Is Nicotine?”)

Still, UAB pulmonologist William Bailey, M.D., says he doesn’t like the concept of e-cigarettes at all. “This is less dangerous than smoking cigarettes,” he says. “It’s clearly less of a toxic substance, but that doesn’t make it a good thing.”

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Cherie says that for her, “it’s sort of like using a nicotine patch,” but with a pacifier effect that helps her for the time being: “It seems like a good alternative until I can quit.” Users can buy nicotine cartridges in different strengths, much like nicotine gum and patches, so she can step down gradually. “They go all the way down to zero,” she says.

That pacifier effect is what Bailey fears could perpetuate the two hardest habits for smokers to break: having a cigarette with a morning cup of coffee and having a cigarette with an alcoholic drink, especially in social settings. Faux-cigarette users are more likely setting themselves up to slip back into using the more readily available tobacco versions, Bailey says.

With the gums and patches, “you have broken that hand-to-mouth oral gratification habit,” he says. “With the e-cigarettes, you’re actually encouraging it. I just don’t think people are going to be quitting as easily.”

Proven alternatives—including nicotine gum, patches, lozenges, sprays, and inhalers—are better for several reasons, Bailey says.

“The whole point of all these other cessation devices is that they’re not attractive. They’re not made to be a lot of fun.” For instance, nicotine gum is hard to chew on purpose. “But they do give you some support, and that helps reduce some of the craving and withdrawal symptoms.”

Sweet Temptation

Opponents of e-cigarettes are concerned that they come in flavors such as vanilla and chocolate, which makes them more attractive to minors. But because these flavors cover the harsh taste of pure nicotine, they also are popular with users such as Cherie, who find that flavorings help them focus on the “positive” effects of the drug. Nicotine “does almost whatever you want it to do,” says Bailey. “It will wake you up if you’re sleepy, and it will calm you down if you’re nervous. It’s a very powerful drug; that’s why people get addicted to it.”

What Is Nicotine?

The tobacco plant, Nicotiana tabacum, contains thousands of chemicals, but the key ingredient is spelled out in its first name. Nicotine, also known as C10H14N2, is a naturally occurring compound called an alkaloid (a group that contains another mind-altering substance: caffeine). Nicotine inhaled through cigarettes (or e-cigarettes) passes from the lungs into the bloodstream, where it is carried rapidly to the brain.

Within seconds, nicotine increases heart rate, blood pressure, and breathing rate; it also binds to receptors that activate reward pathways, flooding the brain with the feel-good chemical dopamine. The buzz doesn’t last long, however; after a few hours, enzymes have broken down the nicotine and flushed it out of the brain. Novice smokers may go days and weeks before their bodies start to crave another fix, but long-term users grow so accustomed to the drug-induced state that they experience anxiety and other withdrawal symptoms when nicotine levels drop—and respond by smoking more and more to keep levels as high as possible at all times.

But exactly how nicotine gains control of the smoker’s mind is still poorly understood, says UAB neurobiologist Robin Lester, Ph.D., who has studied nicotine addiction for decades. “That’s the 64-million-dollar question,” he says. “Nicotine doesn’t produce euphoria like heroin or cocaine. In fact, when they first try it, it makes many people sick. But it’s one of the hardest drugs to quit.”

Coffee and Cigarettes

The primary effects of nicotine, including its mood-altering powers and a tendency to sharpen mental focus and curb appetite, are most attractive at first, Lester explains. But eventually what are called the “secondary associative cues” related to smoking—the smell of tobacco, for example, or the pairing of morning coffee and cigarette—become “very, very powerful,” Lester says. In fact, it appears that these cues may be driving the desire for cigarettes in regular smokers maybe more than the physical craving for nicotine itself.

Nicotine replacement strategies such as gum, along with behavioral therapies—for example, slowly increasing the time between drinking morning coffee and having a cigarette to break the association—certainly help many smokers, says Lester. But studies show that up to 80 percent of smokers fail in their attempts to quit, he notes. Lester believes that e-cigarettes, if used as intended, could be an additional tool to help those who have found no success using other nicotine replacement therapies.

In the long run, however, any solution that involves nicotine is likely to be problematic, Lester says. Studies at UAB and elsewhere suggest that even just a handful of brushes with the drug can permanently reshape neural wiring, leaving a lifelong craving for more. “There are some people in the field who argue that once you’ve smoked, basically you’re a smoker or an ex-smoker for life because you’ve changed your brain,” Lester says. His research group is focused on understanding the chemical pathways involved in nicotine addiction—work that may eventually lead to new medications that restore balance in the brain and help more smokers quit.

Push for Regulation

Both Lester and Bailey hope that the Food and Drug Administration (FDA), which has disputed claims from e-cigarette makers that the devices are completely nontoxic, wins legal battles about whether they should be regulated. (On September 9, the FDA sent letters to several U.S. companies warning them to stop making claims that their products can help people quit smoking.) But whatever the final verdict, Bailey says the main goal remains getting smokers to quit.

“There are a lot of ways to do it,” Bailey says. “Many people are able to quit on their own, even if they failed miserably in the past. The average successful quitter has failed five or six times in the past. So don’t give up.”