Researcher Dr.Konstantinos Farsalinos has once again kindly agreed to share his thoughts on his latest research (you can see his interviews on his research into e-cigarettes and the heart here, and his thoughts on the EU attitude towards e-cigarettes here). Also, click here for more interviews about e-cigarettes with other scientist, campaigners and vapers. Once again, thanks to researcher Paul Bergen for conducting this interview for the Ashtray Blog!

This interview discusses the findings in his latest study Evaluating Nicotine Levels Selection and Patterns of Electronic Cigarette Use in a Group of “Vapers” Who Had Achieved Complete Substitution of Smoking (available at Libertas Academica – Freedom in Research. The title describes the essence of the study – examining how people who had successfully quit smoking by using e-cigarettes had done so.

Quitting with Electronic Cigarettes

PLB: First of all I prefer very much the idea of studying people that successfully quit rather than those that failed – though failures do provide useful information, patterns of successes make it much easier to devise useful strategies for the average smoker. Though your group does not give us any idea of how representative they are of smokers who have tried vaping they do seem to present a model that is likely to be of use to smokers thinking of quitting.

KF: It is important to study both success and failure stories. Success stories will give us a guidance on how smokers should approach e-cigarettes, how to use them and what to expect. Studying failures will help us avoid potential pitfalls and may provide information that will eventually assist in the development of more efficient e-cigarettes.

PLB: I also very much like the idea that the pattern derived organically, that is, the pattern naturally arose from how the e-cigarettes were used by self-medicating individuals as opposed to a superimposed protocol. However I am curious about how many of those in your study group had the intention of quitting. I asked this partly in relation to Dr. Polosa’s study in which he found unintended quitting. People who started vaping with the intention of only substituting some smoking ended up quitting. These unintended quitters may have formed part of your group as well since 62% were failed past attempted quitters but all had reduced smoking over time.

KF: My opinion is somewhat unconventional on that issue. I believe that, since all smokers know the adverse effects of smoking, they all want to quit. The problem is that most smokers cannot do it because of the addiction and the pleasure they perceive from smoking. They are just not willing to abandon their smoking experience or deal with the abstinence symptoms. This is the reason why the e-cigarettes may have the potential to help this group of smokers.

It is a substitute for smoking, provides pleasure for the user and, therefore, may be more easily adopted by smokers not as a method to quit but as a method to substitute one pleasure with another, less harmful, pleasure. The nicotine delivery provided by the e-cigarette additionally helps in dealing with the chemical part of the addiction to smoking and reduces the craving to smoke. Therefore, I would divide smokers into those seeking help to quit versus people not doing so. But I believe that everyone wants to quit. In this case, there were indeed several participants in my study who started using the e-cigarette out of curiosity, without having decided to seek help to quit.

Nicotine Concentration when Quitting With ECigarettes

PLB: If I understand the main point of what came of this study is that the average participant began using an e-cigarette and replaced some of their smoking. If the nicotine concentration was low they brought it up to the level where it was pleasurable enough to replace all their smoking with e-cigarette use and then over time began to reduce the concentration. It sounds like a directed protocol – start at a given concentration, raise to the point of where it can substitute for smoking, then reduce the concentration.

KF: The study was a retrospective analysis. We interviewed participants 8 months after quitting and evaluated how they managed to quit smoking by using e-cigarettes. This can provide us valuable information on the strategy we should promote to smokers when they want to use the e-cigarette. The main points would be: don’t be afraid to start with high levels of nicotine, be patient in choosing the appropriate equipment and nicotine strength (I would also add flavours) that suit your needs and preferences and, if you can, try to reduce nicotine intake gradually.

PLB: That final step in reducing the concentration and reports from elsewhere indicating that many vapers eventually go toward zero nicotine formulations does seem to show that e-cigarettes evince less dependence than smoking. This should gladden all the anti-nicotine zealots who argue against e-cigarettes has just an additional route to nicotine addiction. It appears that they may not only avoid the health issues but may counter the addiction itself.

KF: This could be a possibility but I doubt that this can be achieved by everyone. I know that most vapers try to reduce nicotine concentrations in the e-liquids they use. However, in some cases we observe that this is accompanied by a significant elevation in liquid consumption (ml per day). I do not think this is a good thing. My opinion is that it would be preferable to use higher nicotine concentration but less amount of liquid rather than do the opposite.

Let’s not forget that vapers do not become addicted to nicotine because of the e-cigarette. They were already addicted due to smoking, therefore there is no issue of addiction (unless we are discussing about non-smokers using e-cigarettes). I acknowledge that there is a proportion of vapers who are using zero-nicotine liquids, but none should risk relapsing to smoking just because he wants to reduce nicotine intake by e-cigarette. As for anti-nicotine zealots, although I agree that the ideal goal would be to get rid of smoking, nicotine and e-cigarette, their behavior and advice is dangerous for smokers. There is no reason in demonizing nicotine when we are talking about people already getting nicotine by smoking.

PLB: You say that you would prefer vapers use higher nicotine concentration but less liquid - could you elaborate on why? Do you mean simply because it will increase the likelihood of quitting smoking or do you have concerns about the safety of vaping itself?

KF: Studies have shown that nicotine inhalation does not harm the lungs and, as I said before, nicotine itself has minimal effects in promoting smoking-related disease. On the contrary, the issue of flavorings inhalation is unknown territory. These substances may be approved for food use (not all of them, several companies use tobacco extracts which are not approved for food use), but we do not know their effects when heated, evaporated and inhaled. Preliminary data from laboratory studies have shown that some flavorings may have a cytotoxic effect on cultured cells, while cell survival was not dependent on nicotine levels in e-cigarette. Of course, it is difficult to extrapolate the results of laboratory studies to human in vivo effects, and it should be mentioned that we have never seen any liquid being equal to or more cytotoxic than tobacco smoke. However, through research we will be able to define which products are the least harmful to use, and I believe vapers would like to know this.

PLB: Out of interest, has it be proven that when people use higher concentrations of nicotine that they will reduce the amount they inhale? Many of us vapers tend to vape the same no matter what concentration we use.

KF: I wouldn't say proven, but several vapers are seeing that lowering nicotine elevates consumption. The same happens when you switch from regular to light cigarettes. Of course this is not the case in all vapers, but it is very common if the difference in nicotine concentrations is significant (e.g. from 24mg/ml you go to 12mg/ml or 6mg/ml). The advantage of using the e-cigarette is that you can make gradual and small decrements in nicotine concentration and this can help in lowering nicotine without elevating consumption.

Smoking, Electronic Cigarettes and Nicotine Addiction

PLB: You have to wonder if “addiction” (and many of us are questioning the real usefulness of that word) is as closely allied to nicotine as we were led to believe. If e-cigarettes provide similar levels of nicotine, and in roughly the same manner, as smoking then why would there be any reason for them to be less addictive. Is it something else about smoking or about tobacco that could explain that?

KF: A lot of us are commonly using the term nicotine addiction. The real issue is smoking addiction, which is much more complex. Fagerstrom renamed his test for nicotine dependence to test for smoking dependence. Even if we concentrate on the chemical part of smoking addiction, it seems several other chemicals contribute to the addictive potential of nicotine. There are studies showing that tobacco alkaloids like monoamine oxidase inhibitors play an important role in chemical addiction. However, we must be cautious in this issue and make clear that there is no need for non-smokers to start using nicotine (whether this is with smoking or with e-cigarette use).

PLB: You argue against medical regulations in that they would constitute a barrier to many potential quitters and here it seems that successful quitters have self medicated in just the manner that those authorities would like. Unfortunately under medical supervision there might arise just the sort of intrusions that would circumvent what seems to be a natural process. Or at worst, vapers would be deprived of the ability to up the concentration to the “quitting” level. (Dr, Polosa also found that higher concentrations of nicotine were positively associated with quitting success.)

KF: It is imperative that e-cigarettes are allowed to demonstrate their full potential. It is not a coincidence that there is a huge variety of devices, flavours and nicotine strengths. This is because every user has different preferences. The variability will help every smoker choose what he prefers. We don’t need another nicotine inhaler; we need a product which provides satisfaction to the user. If we restrict this or we stop evolution of new more efficient products we will lose a historic opportunity to reduce smoking-related disease.

(Also see: Are Electronic Cigarettes Really As Addictive As Nicotine?)

New Zealand Quit Smoking E-Cigarette Study

PLB: In fact, your study might provide insight into the New Zealand study which ended in headlines about e-cigarettes having the same success as the patch. It turns out that the e-liquid used in that study might have been just not strong enough to do the job for many of the participants (they did not have the ability to affect the concentration).

KF: The authors of the New Zealand study accepted the fact that outdated devices were used. Additionally, it should be mentioned that there is no nicotine-containing liquid available in New Zealand. Users could get them from abroad through the internet only. The results of the study were reasonable and expected, however, if we want to test e-cigarettes in realistic conditions we must be use a different methodology. Give smokers the possibility to use whatever they prefer in terms of flavor and nicotine strength. This is how e-cigarettes work in real life, and the New Zealand study is another example showing why treating e-cigarettes as another medicinal method of smoking cessation grossly underestimates their true potential.

PLB: Yet all participants did reduce smoking by vaping at any strength. This is still good public health in that any replacement is a reduction in harm.

KF: Obviously it is a good thing. But we can do a lot more. The ideal thing is to completely substitute smoking with e-cigarette use.

PLB: While the conclusion that there is greater success in substitution if higher strengths of nicotine are used has been argued for some time it is good to have some formal evidence to back it up. Many regulatory agencies are arguing for only low nicotine strength e-cigarettes to be over the counter and higher to be issued on a prescription basis. If this came to be could it not result in e-cigarettes being less attractive to smokers than to non-smokers?

KF: Nicotine plays an important role in e-cigarette acceptance and effectiveness. This should be made clear to the regulatory authorities and I think they know it. However, until e-cigarettes were invented, we were used to hearing about nicotine levels of 1mg (present in the smoke of one tobacco cigarette). Now we are discussing about 18mg/ml or even more. The numbers may sound high; however, there is no risk of overdose or poisoning for the e-cigarette user and I have tried through my research to show that the evaporation rate is too slow to cause any problems. On the contrary, we should make e-cigarettes more efficient in nicotine delivery and absorption. This is another reason why evolution and development of new products should not be hindered by any strict regulation.

Effectiveness of Zero Nicotine Electronic Cigarettes

PLB: In Canada our agency Health Canada has no problem with zero-nicotine e-cigarettes but is antagonistic toward any e-cigarettes that contain nicotine. Given your results one could argue that they are promoting the one version of e-cigarettes that are the least likely to compete with smoking.

KF: Unfortunately, such a decision makes no sense. It is rare for a smoker to manage to quit smoking by using a 0-nicotine liquid. Health authorities should accept that nicotine has a minimal (if any) long term impact in smoking-related disease. Accepting long-term nicotine intake by a less harmful product such as the e-cigarette is the key in reducing smoking prevalence and providing an important gateway from smoking to the vast majority of smokers who are unable or unwilling to quit with currently-approved methods.

PLB: Thank you once again for your time.