Editorial
E-Cigarette: A Modern Trojan Horse?
Cigarrillo electrónico: ¿un moderno caballo de Troya?
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"apellidos" => "de Torres" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289615000952" "doi" => "10.1016/j.arbres.2015.03.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289615000952?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915001676?idApp=UINPBA00003Z" "url" => "/15792129/0000005100000007/v1_201506250123/S1579212915001676/v1_201506250123/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "E-Cigarette: A Modern Trojan Horse?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "313" "paginaFinal" => "314" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Daniel Buljubasich" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Daniel" "apellidos" => "Buljubasich" "email" => array:1 [ 0 => "dbulju@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Español de Rosario, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Tabaquismo de la Asociación Latinoamericana del Tórax (ALAT)" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cigarrillo electrónico: ¿un moderno caballo de Troya?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Smoking is an addiction that is widespread throughout the world. According to the World Health Organization (WHO), it is the leading cause of preventable death in developing countries. Despite this, therapeutic resources are limited.</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are only three first-line pharmacological treatments for this severe disease: nicotine, bupropion and varenicline, all of which have low success rates, with OR ranging from 1.6 to 2.31 vs placebo at 6 months, and even lower at 24 months.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> This highlights the need for more effective treatments for this illness that is associated with such high morbidity and mortality rates.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2003, the electronic cigarette (E-cig) was launched on the market, supposedly to treat nicotine addiction. Within a short period, awareness and use of E-cigs became widespread. In a survey carried out in 2009 and repeated in 2010, awareness rose from 16.4% to 32.2%, and users from 0.6% to 2.7% (and growing).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> In September 2013, the United States Centers for Disease Control and Prevention reported that the use of E-cigs had doubled among middle and high school students in 2011–2012, estimating that 1.78 million students had tried them by year-end 2012.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> Various studies have shown the percentage of young users to be between 13% and 20%. Concern is heightened by the fact that approximately 4% were previously non-smokers. Another survey in 4 countries found that 70.4% of participants used E-cigs to obtain nicotine in smoke-free spaces.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">All this shows that the use of e-cigarettes transcends the notion of a treatment for smoking cessation, and must be evaluated as a potential medium- and long-term health risk, an incentive for never-smokers to take up the habit, and a means of flouting laws banning smoking in closed spaces.</p><p id="par0025" class="elsevierStylePara elsevierViewall">There are serious doubts as regard their efficacy and safety at the individual level, and even more at the population level. There is no clear evidence of their effect on non-smokers who come into contact with the vapor they emit, which contains nicotine, a highly addictive substance that can be lethal in excessive quantities. Recent evidence shows that nicotine could be a gateway drug due to the existence of a biological mechanism that might explain the progression from cigarette smoking to cocaine use– an effect from which the E-cig is not necessarily immune.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> The E-cig also contains propylene glycol, glycerin, flavoring, nitrosamines and diethinyl glycol, among others. The vapor contains formaldehyde, acetaldehyde, acroleins and heavy metals (nickel, chrome, lead).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Some studies have shown their acute affects on the respiratory tract. Flouris et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> found an acute but clinically non-significant reduction in lung function (reduction in FEV1/FVC but no change in FEV1) after a brief E-cig smoking session, although passive exposure to the E-cig for 1<span class="elsevierStyleHsp" style=""></span>h did not cause any changes. Vardavás et al. analyzed the acute effects of inhalation of an E-cig for 5<span class="elsevierStyleHsp" style=""></span>min on the respiratory tract of 30 healthy smokers, and showed that this did not affect FEV1, FVC, PEF or MEF 50%–75%. There is little more evidence at present on damage in the respiratory tract caused by E-cigs.</p><p id="par0035" class="elsevierStylePara elsevierViewall">However, E-cigs did cause a reduction in exhaled nitric oxide levels and an increase in peripheral airway resistance and impedance, similar to those observed shortly after the inhalation of tobacco smoke.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> The use of E-cigs can cause dry cough, probably due to the exposure to polyethylene glycol and glycerol in the vapor, although this fades after several weeks of use.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> One case of lipoid pneumonia in a 42-year-old woman who used E-cigs for 7 months has been published, but the presence of significant comorbidities meant that this could not be conclusively attributed to E-cigs.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> No studies have been published on the role of E-cigs in the impairment of respiratory function in patients with chronic lung disease, a common phenomenon in long-term cigarette smokers.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Their beneficial effects on smoking cessation or reducing nicotine damage have not been proven. Only 5 studies have been conducted to date, 3 of which had few patients and were not randomized or controlled. Two projects, the ECLAT study and the ASCEND study, evaluated efficacy and safety. The ECLAT study was a prospective 12-month randomized study that evaluated the efficacy of E-Cigs in achieving abstinence or reduction in a group of 300 smokers who did not wish to quit. It compared 2 nicotine doses and placebo. There was a reduction in all groups, with no significant differences between groups and no major side effects.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> In the ASCEND study, a group of smokers who were motivated to quit were assigned to 3 treatment arms: (a) 16<span class="elsevierStyleHsp" style=""></span>mg nicotine E-cig; (b) 21<span class="elsevierStyleHsp" style=""></span>mg nicotine patches and (c) E-cig without nicotine. Low intensity behavioral support was given. After 6 months, the abstinence rate for the E-cigs + nicotine group was 7.3%, for the patches 5.8% and for the E-cigs with no nicotine, 4.1%.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> Superiority could not be demonstrated in any of the groups, nor were there differences in adverse effects. Major conclusions could not be drawn from either study, either because the results lacked statistical significance or due to methodological errors. There was no blinding in any group, and the ASCEND study had serious limitations: subjects using the E-cig knew that they were using a new form of treatment, drop-outs and losses to follow-up were higher in the patch group, and those who received E-cigs did so cost-free at home while the patch group had to pay 4 Euros in the pharmacy for theirs.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In view of these data, it is obvious that better designed, more methodologically rigorous clinical studies are required before convincing conclusions can be drawn.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A recent document issued by the Forum of International Respiratory Societies, which brings together: the Latin American Chest Society, American College of Chest Physicians, American Thoracic Society, European Respiratory Society, Asian Pacific Society of Respirology, International Union Against Tuberculosis and Lung Disease (THE UNION) and the Pan African Thoracic Society, analyzed the subject in depth, suggesting that E-cigs should be regulated as medicinal products. This includes prohibiting their promotion for use in smoking cessation until their risks, benefits and safety margin can be established, as required by regulatory agencies for other products.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> This document echoes the recent statement issued by SEPAR,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> and is a clear example of the position that scientific bodies should take. The WHO has also recently taken a similar stance.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The position statement issued by the Forum of International Respiratory Societies also evaluated the inclusion of recommendations on this device in the Framework Convention on Tobacco Control, including prohibiting its sale, advertising, promotion and sponsorship. E-cigs would also be included in measures to combat exposure to second-hand smoke.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is time to take decisions, and these must be carefully analyzed. The scientific societies have taken the first step in this respect. Regulating E-cigs as a medicinal product is absolutely essential. We need clear scientific evidence in the form of methodologically rigorous studies not sponsored by the electronic cigarette and tobacco industry, particularly since tobacco companies in recent years have acquired licenses for marketing electronic cigarettes, thus putting users at even greater risk.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We are no longer misled by tobacco companies, so let us now keep up our guard and prevent the E-cig from becoming the new Trojan horse.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Buljubasich D. Cigarrillo electrónico: ¿un moderno caballo de Troya?. Arch Bronconeumol. 2015;51:313–314.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treating tobacco use and dependence 2008 update. Practice guideline" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.C. Fiore" 1 => "C.R. Jaén" 2 => "T.B. Baker" 3 => "W.C. Bailey" 4 => "N.L. Benowitz" 5 => "S.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 82 | 25 | 107 |
| 2024 September | 65 | 15 | 80 |
| 2024 August | 89 | 36 | 125 |
| 2024 July | 58 | 14 | 72 |
| 2024 June | 87 | 32 | 119 |
| 2024 May | 89 | 25 | 114 |
| 2024 April | 73 | 24 | 97 |
| 2024 March | 57 | 14 | 71 |
| 2024 February | 28 | 20 | 48 |
| 2023 March | 15 | 8 | 23 |
| 2023 February | 55 | 18 | 73 |
| 2023 January | 52 | 31 | 83 |
| 2022 December | 50 | 37 | 87 |
| 2022 November | 82 | 31 | 113 |
| 2022 October | 60 | 31 | 91 |
| 2022 September | 52 | 44 | 96 |
| 2022 August | 53 | 47 | 100 |
| 2022 July | 49 | 45 | 94 |
| 2022 June | 37 | 43 | 80 |
| 2022 May | 57 | 43 | 100 |
| 2022 April | 44 | 25 | 69 |
| 2022 March | 39 | 47 | 86 |
| 2022 February | 56 | 33 | 89 |
| 2022 January | 54 | 33 | 87 |
| 2021 December | 48 | 37 | 85 |
| 2021 November | 47 | 53 | 100 |
| 2021 October | 55 | 44 | 99 |
| 2021 September | 36 | 42 | 78 |
| 2021 August | 23 | 30 | 53 |
| 2021 July | 36 | 26 | 62 |
| 2021 June | 50 | 32 | 82 |
| 2021 May | 33 | 23 | 56 |
| 2021 April | 64 | 72 | 136 |
| 2021 March | 55 | 18 | 73 |
| 2021 February | 28 | 16 | 44 |
| 2021 January | 30 | 20 | 50 |
| 2020 December | 30 | 15 | 45 |
| 2020 November | 59 | 16 | 75 |
| 2020 October | 33 | 17 | 50 |
| 2020 September | 35 | 10 | 45 |
| 2020 August | 26 | 14 | 40 |
| 2020 July | 26 | 25 | 51 |
| 2020 June | 21 | 8 | 29 |
| 2020 May | 27 | 16 | 43 |
| 2020 April | 33 | 21 | 54 |
| 2020 March | 24 | 10 | 34 |
| 2020 February | 43 | 32 | 75 |
| 2020 January | 28 | 20 | 48 |
| 2019 December | 46 | 27 | 73 |
| 2019 November | 50 | 22 | 72 |
| 2019 October | 49 | 21 | 70 |
| 2019 September | 29 | 10 | 39 |
| 2019 August | 36 | 18 | 54 |
| 2019 July | 29 | 19 | 48 |
| 2019 June | 23 | 17 | 40 |
| 2019 May | 43 | 13 | 56 |
| 2019 April | 42 | 34 | 76 |
| 2019 March | 58 | 29 | 87 |
| 2019 February | 51 | 21 | 72 |
| 2019 January | 44 | 25 | 69 |
| 2018 December | 46 | 16 | 62 |
| 2018 November | 63 | 25 | 88 |
| 2018 October | 78 | 19 | 97 |
| 2018 September | 39 | 11 | 50 |
| 2018 May | 12 | 0 | 12 |
| 2018 April | 66 | 7 | 73 |
| 2018 March | 43 | 9 | 52 |
| 2018 February | 54 | 11 | 65 |
| 2018 January | 192 | 7 | 199 |
| 2017 December | 231 | 7 | 238 |
| 2017 November | 63 | 5 | 68 |
| 2017 October | 18 | 12 | 30 |
| 2017 September | 20 | 14 | 34 |
| 2017 August | 24 | 8 | 32 |
| 2017 July | 21 | 11 | 32 |
| 2017 June | 27 | 13 | 40 |
| 2017 May | 39 | 17 | 56 |
| 2017 April | 30 | 14 | 44 |
| 2017 March | 20 | 16 | 36 |
| 2017 February | 23 | 11 | 34 |
| 2017 January | 11 | 9 | 20 |
| 2016 December | 30 | 15 | 45 |
| 2016 November | 30 | 10 | 40 |
| 2016 October | 35 | 14 | 49 |
| 2016 September | 52 | 17 | 69 |
| 2016 August | 36 | 10 | 46 |
| 2016 July | 35 | 12 | 47 |
| 2016 March | 2 | 0 | 2 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 9 | 10 |
| 2015 October | 47 | 2 | 49 |
| 2015 September | 0 | 1 | 1 |
| 2015 August | 0 | 1 | 1 |
| 2015 July | 3 | 7 | 10 |
| 2015 June | 1 | 1 | 2 |
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