November 21st, 2014

Informing Ourselves About E-Cigarettes

Dr. Sunil Khushalani, a respected colleague of mine at Sheppard Pratt Hospital in Towson, specializes in working with patients who have both addictions and other major psychiatric disorders. Tobacco addiction continues to be much more prevalent in this group than in the general population. Controversy has developed around the question of whether electronic cigarettes are a help or a hindrance in dealing with this problem. Dr. Khushalani has reviewed the burgeoning literature on this subject and gives us a concise summary in this week’s blog on e-cigarette use.

By Dr. Sunil Khushalani

Cigarettes cause more than 480,000 deaths annually in the U.S. Seventy percent of smokers say that they would like to stop smoking, but only 4 to7 percent of people are able to quit. E-cigarette use has now emerged, bringing with them promises and new questions. Time will tell, however, whether they will be actually able to break the stronghold of combustible tobacco products and become a true “breakthrough technology.”

E-cigarettes are designed to emulate the experience of smoking and usually deliver a certain amount of nicotine, but without exposing the user to the highly carcinogenic tar and harmful carbon monoxide gas that cigarettes emit. Many of them look broadly similar to cigarettes, but are often larger and sport different colors; some look very different from cigarettes.

The e-cigarette market has expanded exponentially to the point where it has become a $2 billion dollar industry. There are now close to 500 brands of e-cigarettes and 8,000 unique flavors.1There are substantial differences between these varieties. Therefore, one needs to be cognizant before one chooses to use them or advises others to use them. They are highly variable in quality, appeal, and efficiency.

Increased used and availability of e-cigarettes has also added some new terms to our lexicon. “Vaping” denotes the inhalation of the vaporized solution. “E-liquid” or “juice” is the liquid solution vaporized by e-cigarettes. It usually contains water; propylene glycol or glycerin; nicotine; or flavorings.  “Atomizer” refers to the part of the e-cigarette that heats the e-liquid for vaporization. E-cigarettes either use refillable cartridges or a refillable tank (Adding more e-liquid is called “dripping.”).

Proponents of e-cigarettes feel that they are a viable harm-reduction strategy, which can reduce morbidity and mortality. This reduction, if achieved, could be vital, as our existing methods have yielded limited success. They also feel that the amount of toxicants in e-cigarettes is, in terms of magnitude, lower than that in cigarettes.

Opponents are not convinced of their safety. They argue that smokers should use current evidence-based strategies. They also think that e-cigarettes will act as a  “gateway” and that youth can get hooked to nicotine from their use. Poison Centers have received more than 200 calls a month this year for nicotine-related poisoning, and more than half of these cases involved children in accidental poisoning.

Both proponents and opponents, however, agree that there is need for better regulations (e.g., restricted advertising and sale to minors). Robert West, an epidemiologist, writes, “We have to accept that it will probably be more than 30 years before we would have a chance of being able to use epidemiology to quantify risks from e-cigarette use.”2 Meanwhile, we have to educate ourselves so that we can approach this new technology with an informed lens.


  1. Shu-Hong, Zhu et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tobacco Control 2014; 23; iii3-iii9
  2. West, R. and Jamie, B. Electronic Cigarettes: fact and faction. British Journal of General Practice, Sept 2014


Dr. Sunil Khushalani is the Service Chief of the Co-Occurring Disorders Inpatient Unit and the Adult Day Hospital at the Towson Campus of Sheppard Pratt Hospital. He is Board Certified in Psychiatry by the American Board of Psychiatry and Neurology. He is also a Diplomate of the American Board of Addiction Medicine.

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