The e-cigarette is not suitable for smoking cessation

Professor Pankow, can you tell us: are e-cigarettes more dangerous, less dangerous or just as dangerous as cigarettes with tobacco?

Pankow: That's not so easy to answer. Toxicological studies show that smoking e-cigarettes releases certain harmful substances in lower concentrations than tobacco consumption. Nevertheless, harmful substances such as formaldehyde or fine dust are inhaled and sometimes even absorbed in higher concentrations than through conventional cigarettes.

What are the consequences?

Pankow: We now know that the ingredients in e-cigarettes have a damaging effect on the lungs, cardiovascular system and immune system, and some are even carcinogenic. Whether the overall damage is less than that caused by tobacco smoke cannot currently be said with certainty. We still lack the long-term studies.

What about the nicotine content in e-cigarettes?

Pankow: There are e-cigarettes with different nicotine contents. However, it is often just as high as in conventional cigarettes. This is problematic because nicotine is a very powerful addictive substance. There is also evidence from laboratory studies and animal experiments that nicotine has a carcinogenic effect.

Manufacturers advertise e-cigarettes as a way to quit smoking. Others claim that they often promote smoking in the first place. What is it now?

Pankow: The weaning effect of e-cigarettes is still largely unclear. There are few controlled studies that have shown a slight advantage over nicotine replacement products. Longitudinal studies, which are more likely to be transferrable to reality, have produced rather negative results. The fact is: Most e-cigarette users do not stop consuming cigarettes, but consume both at the same time.

So you wouldn't recommend e-cigarettes as a smoking cessation tool?

Pankow: Right. E-cigarettes are not a regulated medical product and their side effects are not yet foreseeable. Therefore, the tried and tested nicotine replacement products (NRT) or other medications that reduce the craving to smoke are to be preferred for smoking cessation. In a statement, the German Society for Pneumology and Respiratory Medicine (DGP) also clearly spoke out against the recommendation of e-cigarettes for smoking cessation. It relies in particular on current analyzes and statements from national and international pneumological and child and adolescent psychiatric scientific specialist societies.

What do you recommend to people who want to quit smoking?

Pankow: Various aids have proven their worth in smoking cessation, in particular nicotine replacement products, but also drugs such as varenicline, which are effective and whose safety has been proven. The so-called "gold standard" in smoking cessation is the combination of behavioral therapy plus drug support. A success rate of up to 40 percent can be achieved after one year. However, this also means that many smokers, despite all their attempts, are unable to stop smoking permanently. That is why we keep emphasizing that prevention – i.e. preventing young people in particular from starting to smoke in the first place – is the most important thing.

Why are evidence-based smoking cessation methods so rarely used?

Pankow: That is indeed a problem. Most smokers want to quit smoking, but are unable to. And although around 30 percent of hospital patients in Germany smoke, only a few clinics offer professional smoking cessation. Another obstacle is that the costs for the medication are currently not covered by the statutory health insurance companies in Germany. We advocate changing that. Pharmacological support increases the likelihood of quitting tobacco use and should therefore be offered to all patients.

The industry promotes e-cigarettes as a clean, odorless and stylish lifestyle product. What do you counter that?

Pankow: The proponents of e-cigarettes claim that consumption is not as harmful as normal smoking and can also contribute to weaning. Neither has been proven. Also: A less harmful product is far from acceptable, especially if you cannot really assess the dangers. We see that the e-cigarette has the potential to become a gateway drug, especially among young people. The fact that it is sometimes even touted as health-promoting in the sense of “harm reduction” is absurd. We really have to be careful that this doesn't create a new generation of smokers. After all, we have had good success with smoking cessation in young people in recent years. We shouldn't spoil that.

In your experience, what are the most effective arguments to get people to stop smoking?

Pankow: With young people, it's definitely the price. A lot can be achieved by increasing the tobacco tax. For adults, it is more health considerations that make them want to quit smoking.

Could attitudes towards smoking also change as a result of the corona pandemic?

Pankow: There is reason enough for that. We know that smoking is a significant risk factor for contracting the coronavirus and for developing a severe course of COVID-19. A meta-analysis even found a 39 percent increase in mortality from COVID-19 in smokers. Smoking is also a major risk factor for other respiratory infections such as pneumonia, influenza or tuberculosis - and this also applies to e-cigarettes. The corona pandemic should therefore be an opportunity to offer all smokers professional, multimodal tobacco cessation.

Prof. Dr. medical Until 2019, Wulf Pankow was chief physician of the clinic for internal medicine - pneumology and infectiology at the Vivantes Klinikum Berlin-Neukölln and represents the German Society for Pneumology and Respiratory Medicine (DGP) in the Non-Smoking Action Alliance. V