The case of electronic cigarettes is giving rise to various proposals and positions. In these opposing views, the concepts of tobacco dependence and treatment are often confused in rather crude ways.
The electronic cigarette was created as a product for smokers, as an alternative to tobacco. At first glance, it could be considered a way of replacing nicotine while preserving the gestures and aesthetics of cigarette smoking, but with a less toxic mixture.
All the toxicity associated with cigarette combustion products is eliminated, with a major benefit in terms of the risk of cancer and damage to the respiratory system.
The cigarette, however, has a second characteristic: the liquid mixture that is vaporized is “concentrated” compared with tobacco in terms of its nicotine content. This higher concentration makes the electronic cigarette less manageable, because repeated inhalation of nicotine-containing vapor is followed by a gradual increase in nicotine levels in the blood. Initially, the levels are low, but with prolonged electronic smoking they tend to become similar to those produced by tobacco smoking. The possibility of obtaining a desirable “peak” nicotine level is lower: in order to keep nicotine at a desirable level—neither too little nor too much—the person would have to reduce the frequency of “puffs,” but this is difficult for someone who is dependent. A dependent person will therefore tend to take repeated puffs, as they would with a tobacco cigarette, but will tend to raise nicotine levels to the point of producing a state of pre-intoxication (nausea).
As a result, the electronic cigarette is not a substitute in the strict sense, because it does not induce the same relationship with nicotine as a tobacco cigarette. At the same time, the mechanism of nicotine “saturation” that develops leads to a reduction in the desire to introduce additional nicotine by other means.
When considering a person with severe nicotine dependence, the point is not simply that they switch to using an electronic cigarette, but that, by using the electronic cigarette, they reduce their smoking of tobacco cigarettes, potentially reaching complete and stable cessation.
The “novelty” of the electronic cigarette therefore does not lie in the fact that it is a more pleasant and natural method for quitting smoking because it preserves the form and gestures of tobacco cigarette smoking. The novelty lies instead in its potential therapeutic use, as a tool for obstructing tobacco smoking in people who have lost control over it (nicotine dependence).
The appropriate approach in this case would not be so much a transition from nicotine to “electronic” nicotine, but rather an assessment of how effectively “electronic” nicotine can limit the consumption behavior associated with “plant-derived” nicotine.
For example, several people report that, with an electronic cigarette, they are able to maintain a much lower level of tobacco consumption (for example, reducing from two packs to five cigarettes), while naturally continuing to take a certain amount of “electronic” nicotine each day. This dose, when measured in “cigarettes,” is naturally small, even though the actual amount of nicotine consumed may be equal to or greater than before.
There may therefore be situations in which tobacco consumption is lower but nicotine consumption is higher, as well as situations in which nicotine consumption remains the same while tobacco consumption is lower.
In fact, there are also medications capable of acting in a similar way, or at least partly through a mechanism of this type. Varenicline is a substance that acts on nicotinic receptors and produces a certain degree of “nicotine signaling,” through which the brain experiences a reduction in the desire to consume tobacco. At the same time, with varenicline, if the person smokes while taking the medication, they do not experience the nicotine effect. If the desire has already been sufficiently reduced by the medication’s nicotinic action, the residual desire will easily fade away.
For someone who needs a stronger saturation signal because their desire for nicotine is greater, the electronic cigarette may play an important role, at least as a first stage in distancing themselves from tobacco.
The only genuinely negative anomaly of the electronic cigarette is the fact that it is a non-medical product, freely available for purchase, and its use is left to self-management, whereas it would make sense for the person to receive medical guidance regarding how it should be used and what it may be useful for. The potential danger lies in the fact that a “light” smoker could become intoxicated more easily by the concentrated nicotine. However, because of the rapid rise in nicotine levels produced by inhaled “electronic” nicotine, this probability is in fact self-limiting.
Many people use electronic cigarettes in order to “quit smoking,” which may make sense, but may also not make sense if the person intends to treat a nicotine dependence. Nicotine dependence is not a disorder generated by the discomfort that arises when one does not smoke. Rather, dependence is a disorder characterized by an uncontrolled desire that conflicts with one’s intentions and therefore tends to produce a condition of continuous or recurrent intoxication, as well as an investment of energy and effort in obtaining the substance, controlling its consumption, or dealing with the consequences of intoxication.