Ask the Flight Surgeon / By MAJ Jacob Mathew, Jr. DO, FACOI.: Q: I'm a 24 year old crew chief, who just finished a combat deployment. I was smoking during the deployment due to the stress but now that I am back, my spouse wants me to quit. I have seen many of other soldiers “vaping” as a method to quit smoking. What is the data behind nicotine cessation with electronic cigarettes (e-cigarettes)? Are there any risks to e-cigarettes? Will this affect my flight status?
Tobacco smoking is the largest single preventable cause of many chronic diseases and death, causing more than 5 million deaths worldwide each year (1) (2). Most people struggle to achieve long-term abstinence, and unfortunately, often relapse due to the highly addictive main ingredient, nicotine (1)(2). Studies have suggested that a large amount of the toxicity associated with tobacco use is related to its “combustion” process, thus it was proposed that if we can eliminate this combustion factor, we may be able to reduce the harm imposed on users (1).
Enter, the electronic cigarette (e-cigarette). The e-cigarette is a battery-operated nicotine delivery device that heats a cartridge containing liquid, resulting in the production of a chemical-filled aerosol, which is then inhaled into the lungs. This inhalation is termed “vaping” (3). The liquid is often a combination of liquid nicotine and a stabilizing compound, which together may be not only more addictive than cigarettes, but also as harmful to the user and those around them. E-cigarettes can come in various forms, to include e-pens, e-hookah, and others, collectively known as electronic nicotine delivery systems (ENDS) (4). The nicotine industry has marketed e-cigarettes as “safe” alternatives to smoking. As a result, it has been become a popular method for smoking cessation (4)(5). Due to its marketing, public perception is that e-cigarettes are safer than traditional tobacco (6). Unfortunately, e-cigarettes are still harmful to one's health and studies worldwide are showing that e-cigarettes may eventually lead to traditional tobacco use in previous non-smokers (7)(8).
The FDA has not formally approved any e-cigarette as either a safe, or effect, method to help smokers quit (9). No conclusive data has demonstrated that e-cigarettes lead to substantial cessation rates(10). This may be due to the fact more than half of e-cigarette users concurrently use cigarettes (9). There is abundent evidence that successful treatment of nicotine addiction improves mortality, regardless of age at cessation. While beyond the scope of this article, there are more heavily studied nicotine replacement therapies (NRT) on the market that are FDA approved. These include: varenicline, the patch, gum, lozenges, and Wellbutrin(11). There are established aeromedical policy letters dedicated specifically to these cessation options. Seek out your local flight surgeon for more details.
With the advent of e-cigarettes which first debuted on the market in 2004, there has been an unprecedented shift we have seen in the medical field from cigarettes to electronic cigarettes, especially as they continue to be marketed as a smoking cessation tool (14). Within 12 years, up to 3.2% of adults in the United States were reported e-cigarette users, with a 900% increase in high school users alone from 2011 to 2015 (4). E-cigarettes may have a role in reducing the health-related harms of cigarettes, through not only assisting smoking cessation attempts but also supporting long-term abstinence from smoking by substituting the physical, psychological, social, cultural and identity-related aspects of tobacco addiction.(15)
Their true “safety” however remains to be seen and a growing body of research suggests that vaping may not be as safe as previously advertised. The U.S. Surgeon General has warned the public that e-cigarettes expose users to multiple dangerous compounds other than nicotine to include formaldehyde (used to preserve human bodies), lead, the main ingredients in anti-freeze, and other known carcinogens(16)(13) (7)(17)(6). These compounds have been ultimately the cause for not only cancer, but irreversible lung damage, and poisonings to bystanders exposed to the vapor (6)(18)(12)(13). While they have been touted as having less carcinogens than cigarettes, their nicotine content may be dangerously high and lead to higher rates of addiction, as evidenced by Israel recently banning the import of all Juul e-cigarettes due to the “grave risk” they pose to public health (19). The U.S. military has also specifically alerted soldiers on the risks of vaping products. At Ft. Bragg, e-cigarettes were directly linked to the hospitalization of over 60 military personnel due to high concentrations of cannibis present. The products that were specifically identified included “CBD Vape Oil”, “Vape Juice”, “Vape Oil” and “E-liquid.” See Criminal Alert Notice (CAN) 00014-2018-CID101 for more information.
No formal aeromedical policy letter (APL) exists regarding the use of e-cigarettes and flying. As a result, a discussion between the crew member and the flight surgeon is recommended to include potential risks of using them. The use of e-cigarettes in or around the aircraft is strictly prohibited.
Although e-cigarettes have been touted as an effective and safe method for smoking cessation, further research is required to fully understand the risks they pose to the user (20). They should not be considered healthy, and patients should understand the risks their use pose. Patients should nonetheless be applauded when they desire to quit tobacco and should reach out to their local flight surgeon regarding the plethora of approved options they have and how it may affect their flight duties.
1. Farsalinos KE, Le Houezec J. Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes). Risk Manag Healthc Policy. 2015;8:157–67.
2. Nicotine Addiction [Internet]. [cited 2018 Aug 22]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/
3. E Cig vs Vape | Difference Between E Cigs & Vapes | Logic Vapes [Internet]. [cited 2018 Aug 24]. Available from: https://logicvapes.us/ecigs-versus-vapes
4. E-cigarettes: How they work, benefits, and risks [Internet]. Medical News Today. [cited 2018 Aug 24]. Available from: https://www.medicalnewstoday.com/articles/216550.php
5. National and State Trends in Sales of Cigarettes and E-Cigarettes, U.S., 2011–2015 - ScienceDirect [Internet]. [cited 2018 Aug 24]. Available from: https://www.sciencedirect.com/science/article/pii/S0749379717300223
6. E-Cigarettes: Are They Really a ‘Safe' Alternative to Cigarettes? - UAB Medicine News - UAB Medicine [Internet]. [cited 2018 Aug 24]. Available from: https://www.uabmedicine.org/-/e-cigarettes-are-they-really-a-safe-alternative-to-cigarettes-
7. Health CO on S and. Smoking and Tobacco Use; 2016 Surgeon General's Report [Internet]. Smoking and Tobacco Use. 2018 [cited 2018 Aug 24]. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/
8. Tam J, Warner KE. Students' Cigarette Smoking and the Perceived Nicotine Content of Their E-cigarettes. Am J Prev Med. 2018 Sep;55(3):376–83.
9. E-cigarettes and Lung Health [Internet]. American Lung Association. [cited 2018 Aug 24]. Available from: http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html
10. Beard E, West R, Michie S, Brown J. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ. 2016 Sep 13;354:i4645.
11. Drummond MB, Upson D. Electronic Cigarettes. Potential Harms and Benefits. Ann Am Thorac Soc. 2014 Feb;11(2):236–42.
12. Scott A, Lugg ST, Aldridge K, Lewis KE, Bowden A, Mahida RY, et al. Pro-inflammatory effects of e-cigarette vapour condensate on human alveolar macrophages. Thorax. 2018 Aug 13;
13. Formaldehyde [Internet]. [cited 2018 Aug 22]. Available from: https://www.cancer.org/cancer/cancer-causes/formaldehyde.html
14. Glynos C, Bibli S-I, Katsaounou P, Pavlidou A, Magkou C, Karavana V, et al. Comparison of the effects of e-cigarette vapor with cigarette smoke on lung function and inflammation in mice. Am J Physiol Lung Cell Mol Physiol. 2018 Aug 9;
15. Notley C, Ward E, Dawkins L, Holland R. The unique contribution of e-cigarettes for tobacco harm reduction in supporting smoking relapse prevention. Harm Reduct J. 2018 Jun 20;15(1):31.
16. Varlet V. Drug Vaping: From the Dangers of Misuse to New Therapeutic Devices. Toxics [Internet]. 2016 Dec 16 [cited 2018 Aug 22];4(4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606648/
17. Electronic-Cigarettes-Infographic-508.pdf [Internet]. [cited 2018 Aug 24]. Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-508.pdf
18. Environmental Health Perspectives – Flavoring Chemicals in E-Cigarettes: Diacetyl, 2,3-Pentanedione, and Acetoin in a Sample of 51 Products, Including Fruit-, Candy-, and Cocktail-Flavored E-Cigarettes [Internet]. [cited 2018 Aug 24]. Available from: https://ehp.niehs.nih.gov/15-10185/
19. Israel bans Juul e-cigarettes citing “grave” public health risk. Reuters [Internet]. 2018 Aug 21 [cited 2018 Aug 24]; Available from: https://www.reuters.com/article/us-ecigarettes-israel/israel-bans-juul-e-cigarettes-over-nicotine-concentration-idUSKCN1L61YW
20. E-cigarettes should be promoted as a method of stopping smoking [Internet]. ScienceDaily. [cited 2018 Aug 24]. Available from: https://www.sciencedaily.com/releases/2017/10/171009093205.htm
...(download the rest of the essay above)