Statement of the Problem
Cigarette smoking is a harmful past time habit and addiction due to its adverse health effects. The health dangers of tobacco smoking include an increased risk of developing lung cancer, cardiovascular disease, pneumonia, and chronic obstructive pulmonary disease (Meo & Al Asiri, 2014). Current public health campaigns concerning the dangers of tobacco smoking have had a positive impact on the habit of smoking as more smokers attempt to quit the habit. However, a new smoking trend has emerged that is purported to be safer than tobacco smoking. There is a significant increase in the popularity of electronic cigarettes (e-cigarettes) in developing countries, including the USA (Grana, Popova, & Ling, 2014).
Using e-cigarettes allegedly does not entail the combustion of tobacco. Instead, nicotine and the other constituents are converted into an aerosol before inhalation. Even though the absence of combustion reduces exposure to toxic substances compared with conventional cigarettes, there is a risk of secondhand as well as thirdhand exposure to harmful substances through direct contact with the components of the e-cigarettes or breathing in secondhand aerosol. Therefore, it is important to conduct a comparative study to determine the effects of electronic smoking vis-a-viz traditional cigarettes to help the public to make informed choices.
Review of the Literature
Tobacco is a cultivated plant whose leaves are harvested, dried and fermented before using them in tobacco products. The active ingredient in tobacco is nicotine, an addictive substance that makes it difficult for tobacco users to quit. Using tobacco products leads to the rapid absorption of nicotine into the bloodstream where it leads to the secretion of the hormone adrenaline by the adrenal cortex (Callahan-Lyon, 2014).
Adrenaline works on the central nervous system to cause a rise in blood pressure, heart rate, and breathing rate. Nicotine triggers the brain’s reward center and increases the levels of the neurotransmitter dopamine, which strengthens rewarding conduct. Other highly addictive drugs such as heroin and cocaine work in the same way hence their addictiveness. Tobacco smoke also contains the chemical acetaldehyde that augments the effects of nicotine on the brain.
Apart from nicotine, tobacco contains many other harmful chemicals that are produced during combustion. The harmful effects of tobacco arise from additional chemicals that are produced during combustion. Tobacco smoking is associated with health problems such as emphysema, chronic bronchitis, and lung cancer. Smoking elevates one’s risk of cardiovascular disease that may culminate in a heart attack or stroke. Other complications caused by smoking include type 2 diabetes, leukemia, cataracts, pneumonia, and other forms of cancers. Users of smokeless tobacco (hookah) also face the same risks and are predisposed to cancers of the mouth.
Cigarette smoking in pregnant women increases the risk of miscarriage, premature births, underweight infants, or stillborn births (Hua & Talbot, 2016). Children whose mothers smoked during pregnancy are likely to have learning and behavioral difficulties. Standing or sitting close to smokers as they smoke exposes an individual to secondhand smoke, which may come from exhaled vapors or the burning tobacco. Secondhand exposure to tobacco smoke can also cause lung and heart diseases that stem from active smoking. Initial symptoms are coughing, production of phlegm, and reduced function of the lung. In children, secondhand exposure to tobacco smoke predisposes them to lung and ear infections, ear problems, asthma, and sudden infant death syndrome.
Electronic cigarettes (also known as e-cigarettes) are battery-powered gadgets that are created to convey nicotine and other flavors in the form of an aerosol (Coleman et al., 2017). Electronic cigarettes have a heating element, which is responsible for the atomization of a liquid containing all the ingredients of the cigarettes. The resultant aerosol is then inhaled directly by the user through a mouthpiece. The first e-cigarettes were designed based on the outline of traditional cigarettes. However, it has since been modified to enable the customization of the heating element and using different liquids to refill one device. Therefore, e-cigarettes can be single-use or refillable (Dinakar & O’Connor, 2016).
The components of e-cigarettes include glycerine, propylene glycol, nicotine, and flavors (Primack, Soneji, Stoolmiller, Fine, & Sargent, 2015). The concentration of nicotine usually varies from 0 to 24 mg per milliliter. The constituents of the aerosol that is produced are determined by factors such as the electrical attributes of the heating element, the maximum temperatures attained, and wick features. Propylene glycol, glycerin, and most flavors used in e-cigarettes are the same ones included in food additives. Therefore, they are considered relatively safe for oral ingestion. Nonetheless, there is insufficient data regarding the long-term safety of inhaling these substances, particularly in human subjects.
The incidence of e-cigarette use has increased gradually over the years. For instance, Dinakar and O’Connor (2016) report that the proportion of US adults who had used electronic cigarettes rose from 1.8% in 2010 to 13% in 2013. Conversely, current users increased from 0.3% to 6.8% of the population within the same period. Most current users of e-cigarettes were tobacco smokers. However, about 33.3% had previously smoked tobacco or had never smoked it. Findings from a survey involving university students showed that the desire to stop smoking was not the key motivator for e-cigarette smoking. Instead, having mental health problems such as anxiety disorders or depression increased the probability of using electronic cigarettes (Barrington-Trimis et al., 2015; Dinakar & O’Connor, 2016).
Electronic cigarettes produce low concentrations of toxic substances compared to conventional combustible cigarettes (Hua & Talbot, 2016). Consequently, these devices are considered as beneficial tools to mitigate the dangers of tobacco smoking. It is hypothesized that electronic cigarettes can help smokers to cut down the use of old-fashioned tobacco products. Peak serum nicotine levels are attained within 5 minutes of inhaling aerosols from e-cigarettes. The speed of systemic delivery of nicotine coupled with the mode of use (inhalation) mimic traditional cigarettes and elicit the same experience, which can be more effective than other versions of nicotine-replacement therapy to aid smoking cessation (Grana, Popova, & Ling, 2014).
Numerous concerns associated with e-cigarettes have been raised. For example, electronic cigarettes can deter smoking cessation in established cigarette smokers. Using e-cigarettes eases dealing with indoor smoking limitations among smokers. Primack et al. (2015) conducted an observational study that showed that adult smokers who turned to e-cigarettes did not quit traditional cigarettes. Another concern is that the marketing of e-cigarettes could result in the recruitment of nonsmokers. Evidence supporting this concern can be seen in high numbers of teenagers and young adults who currently use e-cigarettes without a history of combustible cigarettes.
The danger of this phenomenon is the reported effects of nicotine on developing brain tissue, which means that more young people are exposed to brain complications attributed to nicotine use (Barrington-Trimis et al., 2015). Studies also suggest that the majority of teenagers and young adults who have been introduced to e-cigarettes had a lower predisposition to nicotine use. This phenomenon raises a critical public health question of whether e-smoking increases the risk of advancing to the double use of e-cigarettes and traditional cigarettes or the total use of cigarettes.
It was initially believed that electronic smoking was safer than traditional smoking because of the absence of combustion. However, there is evidence showing the dangers of electronic smoking to smokers as well as non-smokers. For example, Hess, Lachireddy, and Capon (2016) conducted a systematic review of studies that examined the dangers associated with passive exposure to electronic cigarettes. Homes with electronic cigarette smokers had higher levels of atmospheric nicotine than homes with nonsmokers. Nonetheless, the concentrations of nicotine in the atmosphere were highest in the homes of conventional cigarette smokers.
The authors noted that passive exposure to electronic cigarette smoke led to adverse health effects including, irritation of the respiratory system by carbonyl compounds such as formaldehyde, organ toxicity from heavy metals, and increased serum cotinine levels. However, the risk associated with passive exposure to vapor from electronic cigarettes was lower than from conventional smoking. An additional danger that resulted from secondary exposure to traditional cigarettes included inflammatory responses that were prerequisites for cardiovascular disease (Hess, Lachireddy, & Capon, 2016).
The adverse health effects of e-cigarettes are linked to additional compounds not originally included in the list of ingredients but have been detected through analytical studies. For example, listed liquids in most e-cigarettes are glycerol, propylene glycol, and nicotine. However, other compounds that have been detected through chromatographic and mass spectrometry techniques include acrolein, acetone, 1,3-butadiene, formaldehyde, cyclohexane, ethylene glycol, and diethylene glycol (Goniewicz et al., 2014). Formaldehyde and acetaldehyde are suspected carcinogens (Dinakar & O’Connor, 2016).
Even though their concentrations are lower in e-cigarettes than conventional cigarettes, the actual levels of exposure can only be determined by factors such as aerosol composition across devices and patterns of smoking. Surprisingly, tobacco is not indicated as one of the ingredients. However, tobacco alkaloids such as anabasine, myosmine, and nornicotine have been isolated from certain brands of e-cigarettes. Moreover, aerosols produced by e-cigarettes are reported to contain acetaldehyde, N′-nitrosonornicotine, toluene, and 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone.
Metals such as lead, cadmium, nickel, copper, and tin have also been detected (Dinakar & O’Connor, 2016). The flavors used in electronic cigarettes are mainly aldehydes. Long-term inhalation of these compounds irritates the upper respiratory tract, particularly during the manufacturing process. Therefore, similar effects can be anticipated through the smoking of e-cigarettes containing them.
Public Health Significance
Cigarette smoking is a harmful habit that is associated with adverse health effects, including the heart. Approximately 33% of mortalities associated with heart disease are attributed to smoking and exposure to secondhand smoke (Pisinger & Døssing, 2014). With the knowledge of the dangers of smoking, most smokers are working towards smoking cessation by turning to electronic cigarettes to ease the transition from smoker to non-smoker status. It is assumed that electronic smoking is less harmful than conventional smoking. However, studies show that electronic smoking may be as harmful as traditional smoking.
Electronic smoking exposes the masses to secondhand and thirdhand smoke. Additionally, smokers can make direct physical contact with the constituents of electronic cigarettes. Therefore, there is a need to determine the precise effects of electronic smoking in comparison with conventional smoking. Such knowledge will guide the development of public health policies to safeguard the masses from the dangers of cigarette smoke.
Objective of the Study
The objective of this study is to compare the health effects of electronic and cigarette smoking to ascertain the safety of the former method of smoking.
The key research question of the study is “Is electronic smoking safer than traditional cigarette smoking?”
Studies show that electronic smoking does not allow the smoker to make direct contact with tobacco by aerosolizing nicotine. However, this process does not eliminate exposure to secondary smoke. A number of studies have already shown that there is a significant amount of secondhand exposure to smoke in electronic smoking. Therefore, it is hypothesized that electronic smoking is not safer than traditional cigarette smoking.
Data will be collected by searching online databases for articles on electronic and traditional smoking. Specific databases that will be searched include EbscoHost, CINAHL, Google Scholar, Medline, and PubMed. Precise phrases that will be used to retrieve relevant articles include the dangers of electronic smoking and the effects of e-cigarettes versus traditional cigarettes. The search will be narrowed to include only articles published within the last five years to ensure that current information is availed. An additional exclusion criterion that will be used is selecting only original research papers or systematic reviews of original studies.
Abstracts of chosen papers will be read to determine the appropriateness of the content and guide the selection of articles for further review. Valuable information from the articles will be gleaned and recorded in tables for further analysis. Some of the parameters of interest will include descriptive statistics such as means, mode, and the median age of participants, duration of studies, the type of smoking (electronic cigarettes or traditional cigarettes), health effects of type of smoking, conclusions, recommendations, and implications for public health.
Mode of smoking will be the key independent variable with two factors (electronic or traditional), whereas the health effects of smoking will be the dependent variables. Electronic smoking will refer to the smoking of any battery-powered contrivances to simulate smoking, irrespective of the precise components being inhaled (Callahan-Lyon, 2014). Conversely, traditional smoking will refer to the smoking of combustible tobacco-containing formulations in the form of cigars, cigarettes, kreteks, bidis, or water pipes. The incidence of adverse health outcomes associated with each mode of smoking will be recorded and analyzed using the student t-test at 0.05 level of significance. The resultant p-value used to support or refute the hypothesis.
The mode of evaluation that will be used for the study is a comparative analysis of quantitative data. The purpose of conducting comparative analysis is to develop a better comprehension of causal procedures involved in a phenomenon. Cause-effect relationships in a comparative evaluation are established by comparing discrepancies in the dependent variables (Reale, 2014). This mode was chosen because its focus is to explain similarities and incongruities, which establishes associations between two or more occurrences and gives acceptable explanations.
One benefit of comparative analysis is that it can take many forms. For example, the two major types of comparative analyses are spatial and temporal. In spatial comparative studies, it is possible to contrast a phenomenon across geographical boundaries such as countries, regions, and cultures. In contrast, temporal comparative analysis can compare various time-frames (Yanow, 2014). There is versatility in the types of comparisons because different subject matters can be contrasted. For example, this study will compare the effects of electronic smoking against those of traditional smoking.
Potential confounding variables include an inherent risk of diseases caused or aggravated by cigarette smoking. Examples are having a family history of type 2 diabetes or hypertension. Such people are likely to develop these diseases even without exposure to active or secondhand smoke. Therefore, studies that include such participants are likely to report higher rates of adverse effects of smoking, hence introducing measurement errors.
The study will report the health effects of electronic versus traditional smoking s reported by different authors. Table 1 depicts the study characteristics of the study sample, whereas Table 2 shows a comparison of the dependent and independent variables. Table 3 shows some of the parameters that will be recorded from the articles during the appraisal of evidence.
Descriptive table: Table 1: Characteristics of the study sample.
|Author(s) details||Mean age of participants||Male (n)||Female (n)||Setting|
Bivariate table: Table 2: The distribution of health effects of electronic and cigarette smoking.
|Electronic smoking||Cigarette smoking||Total|
Multivariate table: Table 3: Results of multivariate analysis depicting ORs for health effects of electronic and cigarette smoking.
|Variable||Odds Ratio||95% CI||P-value|
Conducting scientific research that entails the participation of human subjects raises several ethical issues related to values such as human dignity, privacy, autonomy, and physical integrity. These aspects are included in four ethical principles of beneficence, nonmaleficence, veracity, and autonomy (Department of Health, Education, and Welfare & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 2014).
The principle of beneficence requires that researchers should do good to human subjects in the course of their research. Conversely, the principle of nonmaleficence requires investigators to avoid subjecting participants to any harm. In biomedical research, some of the treatments and controls may have adverse health effects on participants. For example, a clinical trial involving the testing of a new drug agent may involve treating the test groups with the target drug and using placebos for the control groups.
While this study design is necessary to ascertain that the observed effects are due to the test substance, withholding treatment to people who need it may lead to negative health outcomes (General Assembly of the World Medical Association, 2014). Therefore, investigators should avoid such situations to protect the wellbeing of their participants.
The ethical principle of veracity refers to the maintenance of trust between a researcher and study subjects, which brings about the issue of privacy and confidentiality. Partakers of research should be assured that any personal information provided in the course of research will not be revealed to unauthorized persons. Furthermore, it may be necessary to conceal the identity of participants in some cases to prevent victimization based on provided information or to encourage honest participation (Novak, 2014).
Autonomy denotes the ability to make informed decisions without coercion, which raises the issue of informed consent. Participants should be briefed about the proposed study as well as any related benefits or dangers of taking part in it. They should be informed that they are free to participate or opt out of the study at any time. To ensure that prospective researchers adhere to the ethical requirements of using human subjects, it is important to obtain ethical clearance before proceeding with the study. In this case, ethical clearance will be obtained from the Institution’s Review Board. Since the study will involve an appraisal of already published evidence, there will be no direct interactions with human subjects. Therefore, the author does not expect to meet any challenges associated with the use of human subjects in research.
The study will ascertain the dangers of electronic smoking compared to traditional smoking. These findings will be used to guide the development of public health policies to restrict the use of electronic cigarettes. An example of such a policy is the enforcement of bans on public smoking of electronic cigarettes, which would minimize the secondhand exposure of nonsmokers. Given that electronic smoking poses a health risk to bystanders, it will be necessary to implement such measures. The findings of the study will inform the development of public health education materials on the dangers of electronic smoking.
The current craze in the use of e-cigarettes can partly be explained by the lack of information regarding the dangers of vaping. The public assumes that e-smoking is a safe alternative to traditional smoking. However, creating awareness about the dangers of vaping to smokers and non-smokers could change this notion and encourage smoking cessation without resorting to e-cigarettes.
Barrington-Trimis, J. L., Berhane, K., Unger, J. B., Cruz, T. B., Huh, J., Leventhal, A. M.,… Chou, C. P. (2015). Psychosocial factors associated with adolescent electronic cigarette and cigarette use. Pediatrics, 136(2), 308-317.
Callahan-Lyon, P. (2014). Electronic cigarettes: Human health effects. Tobacco Control, 23(suppl 2), ii36-ii40.
Coleman, B. N., Rostron, B., Johnson, S. E., Ambrose, B. K., Pearson, J., Stanton, C. A.,… Goniewicz, M. L. (2017). Electronic cigarette use among US adults in the Population Assessment of Tobacco and Health (PATH) Study, 2013–2014. Tobacco Control, 26(e2), e117-e126.
Department of Health, Education, and Welfare & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (2014). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research. The Journal of the American College of Dentists, 81(3), 4-13.
Dinakar, C., & O’Connor, G. T. (2016). The health effects of electronic cigarettes. New England Journal of Medicine, 375(14), 1372-1381.
General Assembly of the World Medical Association. (2014). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. The Journal of the American College of Dentists, 81(3), 14-18.
Goniewicz, M. L., Knysak, J., Gawron, M., Kosmider, L., Sobczak, A., Kurek, J.,… Jacob, P. (2014). Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tobacco Control, 23(2), 133-139.
Grana, R. A., Popova, L., & Ling, P. M. (2014). A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Internal Medicine, 174(5), 812-813.
Hess, I. M., Lachireddy, K., & Capon, A. (2016). A systematic review of the health risks from passive exposure to electronic cigarette vapour. Public Health Research & Practice, 26(2), 1-9.
Hua, M., & Talbot, P. (2016). Potential health effects of electronic cigarettes: A systematic review of case reports. Preventive Medicine Reports, 4, 169-178.
Meo, S. A., & Al Asiri, S. A. (2014). Effects of electronic cigarette smoking on human health. European Review for Medical & Pharmacological Sciences, 18(21), 3315-3319.
Novak, A. (2014). Anonymity, confidentiality, privacy, and identity: The ties that bind and break in communication research. Review of Communication, 14(1), 36-48.
Pisinger, C., & Døssing, M. (2014). A systematic review of health effects of electronic cigarettes. Preventive Medicine, 69, 248-260.
Primack, B. A., Soneji, S., Stoolmiller, M., Fine, M. J., & Sargent, J. D. (2015). Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults. JAMA Pediatrics, 169(11), 1018-1023.
Reale, E. (2014). Challenges in higher education research: The use of quantitative tools in comparative analyses. Higher Education, 67(4), 409-422.
Yanow, D. (2014). Interpretive analysis and comparative research. In I. Engeli & C. Rothmayr (Eds.), Comparative policy studies: Conceptual and methodological challenges (pp. 131-159). London: Palgrave Macmillan.