Cigarettes and their less morbid alternatives

by Quinn O'Neill

*Cigarette smoking is an insidious and on-going public health disaster. If a new virus were killing as many people – more than 400, 000 Americans each year – there'd be widespread panic. Yet smoking-related deaths and disease garner little of the public's attention.

Perhaps we reason that smokers deserve the consequences of their actions because their habit is a choice. But according to the American Cancer Society, almost 90% of adult smokers take up the habit before the age of 18. Adolescents aren't known for their level headedness and a lifetime of addiction seems a harsh penalty for a bad teenage decision.

Tobacco advertising is an important influence on teens' smoking-related decisions. We like to believe that we make free choices as consumers, but the tobacco industry, which better appreciates how impressionable we really are, spends 8 to 10 billion dollars per year on marketing in the US alone. And it works. The CDC acknowledges that there is evidence of a causal relationship between advertising and tobacco use by young people. Studies confirm that teens are exposed to cigarette advertising and that these ads do increase their desire to smoke.

We would never allow ads to feature cartoon characters encouraging kids to drink toxic household cleaners; but for some reason, when it comes to smoking, we do tolerate the marketing of toxic substances to young people. Tobacco advertising will predictably influence teens' behaviors and many of the new smokers it creates will develop serious or fatal disease. The marketing of cigarettes is essentially criminal and it isn't those who succumb to its influence who deserve to be punished. Today's youngsters need protection from the sinister tactics of the tobacco industry. A complete ban on advertising would be ideal, but doesn't seem likely to happen anytime soon. The CDC offers suggestions on how to reduce the influence of these ads on teens, which may be especially useful to parents.

People might reason that mature adult smokers can choose to quit. Of course they can try, but quitting, for the addict, isn't simply a matter of weighing the pros and cons and deciding to stop. It's more like refraining from eating when you're really hungry; addiction has an important physiological component. For many, quitting “cold turkey” would take an enormous and perhaps unrealistic amount of will power. Only about 5% of those who try are successful.

A variety of products and strategies exists to assist smokers in their attempts to quit. These include older, well-tested options and some newer ones that are promising but more controversial. Below is a brief overview, intended only to provide ideas. I would encourage anyone interested in trying one or more of these to investigate them further before making a decision.

Quitting “cold turkey”

This is the oldest and most obvious approach, in which the smoker simply stops the habit. Remarkably, it's still one of the most commonly used methods among those who've quit successfully. A variation is “cutting down to quit”, which may be more gradual but not necessarily easier. Both require an enormous amount of will power and have similar low success rates.

Nicotine replacement therapy (NRT)

These are devices that provide alternative ways of delivering nicotine into the body. They include gums, patches, nasal sprays, inhalers, and lozenges. A recent Cochrane review found that these products increase the rate of quitting success by 50 to 70%. That sounds pretty impressive and it's better than nothing, but with an unassisted quit rate of about 5%, a 70% improvement isn't all that exciting. It means that if we give an NRT to a hundred smokers who are trying to quit, we'd expect an additional 3 of them to have success.


The most common pharmacological aids are bupropion and varenicline and they're intended to reduce cravings. They're generally considered safe and effective and they may be worthwhile additions to other strategies. They aren't available without a prescription, they aren't without side effects, and they aren't for everyone, so consulting a physician would be necessary. Talking to a doctor might also be a good way to learn about additional resources and services, especially those offered locally.

Helplines and social support.

Phone-based counseling and cessation services are offered by a number of groups including the American Cancer Society and the American Lung Association. A national network of tobacco cessation quitlines can be accessed by calling 1-800-QUIT NOW. Setting up your own support system with friends or family members might also be worth a try and would allow for a more customized approach. Seeing a counselor in person might also be helpful. I'd guess that the success of these methods would heavily depend on the nature of the program, the types of services offered, and the skill of the counselor, but there aren't any serious side effects and many of the phone-based services are free.

The next two ideas – smokeless tobacco and electronic cigarettes – are my personal favorites, but they aren't very popular among public health agencies and health care practioners. They do carry a degree of risk, but this is also true of the medications and NRTs. Both smokeless tobacco and e-cigarettes can be viewed as less harmful alternatives to cigarettes or as stepping stones to a completely nicotine-free life.

Smokeless tobacco (ST)

Smokeless tobacco products show considerable promise as smoking cessation aids. A large Swedish study that surveyed more than 6000 participants found that of those who reported using snus (a smokeless tobacco product) at their most recent attempt to quit, 81% of males and 72% of females were successful in quitting compared to 50-60% for NRTs and counseling. At least among Swedes, ST appears to be an effective tool for smoking cessation.

Risks associated with ST seem to be the biggest concern, since these products do contain tobacco and associated carcinogens. The health risks are substantially lower when compared to cigarettes, owing to the lack of combustion, which generates a large number of carcinogenic and toxic compounds, and to their more localized delivery.

Though some studies have reported a greater risk for some types of cancer with ST use, current evidence suggests that this risk is low. Lee and Hamling conducted a systematic review and meta-analysis of North American and Scandinavian studies to compare the cancer-causing effects of smokeless tobacco and smoking. Their analysis revealed a statistically significant increase in risk for oropharyngeal cancer, but this was only associated with the North American data and the effect disappeared when the studies were limited to those published after 1990. The authors concluded that “[a]ny effect of current US products or Scandinavian snuff seems very limited.”

Smokeless products may also cause some undesirable oral problems, like stained teeth and gingival recession. Clearly, ST isn't free of risk and it isn't an ideal alternative, but it is much less harmful than cigarettes and it may be helpful in breaking the nicotine habit entirely. Switching from cigarettes to ST would be a big step in the right direction even if it ends there.


These are relatively new and getting lots of media attention. They're battery-powered devices that deliver vaporised nicotine and closely simulate the look and feel of regular cigarettes. There's no combustion and no tobacco involved. The user inhales vapor rather than smoke, and the practice has been termed “vaping”.

Consumer accounts attest to their potential in smoking cessation. A large international survey reported that 72% of users found that the devices helped them to deal with cravings and withdrawal symptoms and 92% reported reductions in their smoking.

Although scientific evidence for e-cigarettes as a cessation aid is limited, there's an abundance of favorable anecdotal evidence. I've personally met a few people who credit the product with finally getting them off of cigarettes after numerous failed attempts with other methods. Positive comments abound in threads generated by online articles. Whether people use them as a means of quitting nicotine altogether or simply as a substitute, the outcome represents a definite improvement over the alternative. People seem to enjoy being able to breathe more easily and not having their clothes reek of smoke.

Are e-cigarettes perfectly safe? No, nothing is, but the available evidence suggests that they're substantially less harmful than regular cigarettes and comparable in toxicity to NRTs. A 2011 review of the literature by Cahn and Siegel turned up 16 studies of the composition of the e-cigarette liquid. While thousands of chemicals and many dozens of known carcinogens have been identified in cigarette smoke, the e-cigarette cartridges primarily contain propylene glycol, glycerin, and nicotine. None of these components raises serious concern.

The FDA sounded the alarm over two other substances: tobacco-specific nitrosamines and diethylene glycol. The former was detected in two of the 16 studies at trace levels comparable to the amount found in nicotine patches and much lower than in regular cigarettes. Diethylene glycol was detected in one of 18 cartridges studied by the FDA, but not found in any of the other studies. It was an isolated finding. Based on these analyses, it would be reasonable to conclude that e-cigarettes, while not completely free of risk, are relatively innocuous compared to regular cigarettes and on par with NRTs in terms of toxicity. For interested readers, Cahn and Siegel provide a nice overview of the arguments for and against electronic cigarettes in their paper.

Combinations of the ideas mentioned above may further improve the odds of success. Phone based counseling and social supports would work well with any of the other approaches. Bupropion may also be used in conjunction with an NRT, and this might be worth discussing with a physician. Available resources and services can vary from one community to the next, so deciding on the best approach should include some local research.

Two things are clear about cigarette smoking: it's a major cause of morbidity and mortality and it's an incredibly tough habit to break. We don't yet have a perfect cessation product or strategy, but we do have options.

photo source: FDA/