Smoking Cessation with E-Cigarettes in Smokers with a Documented History of Depression and Recurring Relapses

doi:10.4236/ijcm.2011.23046

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International Journal of Clinical Medicine, 2011, 2, 281-284

doi:10.4236/ijcm.2011.23046 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)

281

Smoking Cessation with E-Cigarettes in Smokers

with a Documented History of Depression and

Recurring Relapses

Pasquale Caponnetto1,2, Riccardo Polosa1, Roberta Auditore2, Cristina Russo1, Davide Campagna1

1Smoking Prevention/Cessation Centre, A.O.U, Policlinico-V. Emanuele, University of Catania, Catania, Italy; 2Villa Chiara Com-

munity Therapeutic Rehabilitation Centre (CTA), Mascalucia (Catania), Italy.

Email: [email protected]

Received February 24th, 2011; revised April 16th, 2011; accepted April 30th, 2011.

ABSTRACT

The association be tween nicotin e de penden ce and a ffective d isord ers, particularly major depressive disorder (MDD), is

well known with high prevalence rates being reported for smokers. The reason for this association is not clear, but, it

has been argued that smoking may help individuals to cope with stress or medicate depressed mood. Smoking cessation

programs are useful in helping smokers to quit, but smoking is a very difficult a ddiction to break, especially for people

suffering from depression, and the need for novel and effective approaches to smoking cessation interventions for this

special population is unquestionable. The e-cigarette is a battery-powered electronic nicotine delivery device (ENDD),

which may help smokers to remain abstinent during their quit attempt. Here, we report for the first time objective

measures of smoking cessation in two heavy smokers, suffering from depression, who experiment the e-cigarette.

Keywords: Smoking Cessation, De pr es sion, Electronic Cigarette, Cigarette Smoking

1. Introduction

Cigarette smoke harms nearly every system of the human

body, thus causing a broad range of diseases, many of

which are fatal [1,2]. The risk of serious disease dimin-

ishes rapidly after quitting and life-long abstinence is

known to reduce the risk of lung cancer, heart disease,

strokes, chronic lung disease and other cancers [3,4].

Although evidence-based recommendations indicate that

smoking cessation programs are useful in helping smok-

ers to quit [5], smoking is a very difficult addiction to

break particularly for people suffering from depression.

The association between nicotine dependence and af-

fective disorders, particularly major depressive disorder

(MDD), is well known with high prevalence rates being

reported for smokers [6,7]. The reason for this associa-

tion is not clear, but, it has been argued that smoking

may help individuals to cope with stress [8] or medicate

depressed mood [9]. Until recent years, the belief that a

history of depression greatly decreases the likelihood of

quitting smoking has b een widely promoted [10]. It must

be noted that the process of cessation itself produces

withdrawal symptoms, which include a variety of mood

disturbances and affective symptoms (depressed mood,

anxiety, nervousness, restlessness, irritability, fatigue,

and drowsiness); these are more pronounced in the days

immediately following cessation and generally return to

baseline levels within a month of continued abstinence.

These differences in mood disturbance appear to be re-

lated to successful cessation as well [11]. Predictably,

smokers reporting higher levels of negative mood and

depressive symptoms were less likely to quit than were

smokers with less mood disturbance [7]. Although it is

generally assumed that a history of depression may be a

barrier to quitting smoking, contradictory evidence also

exists [12,13]. The meta-analysis by Hitsman et al. [12]

shows that lifetime history of major depression does not

appear to be an independent risk factor for cessation fail-

ure in smoking cessation treatment. Likewise, a recent

paper from the Veterans Administration Normative Ag-

ing Study shows that the presence of depressive symp-

toms did not have a significant impact on smoking cessa-

tion [13]. Although there is little doubt that cur-

rently-marketed smoking cessation products increase the

chance of committed smokers to stop smoking, they re-

portedly lack high levels of efficacy—particularly in the

real life setting [14].

Smoking Cessation with E-Cigarettes in Smokers with a Documented History of Depression and Recurr ing Relapses

282

The need for novel and effective approaches to smok-

ing cessation interventions for this special population is

unquestionable. The e-cigarette is a battery-powered

electronic nicotine delivery device (ENDD) resembling a

cigarette designed for the purpose of nicotine delivery to

the respiratory system, where nor tobacco nor combus-

tion are necessary for its operation [8]. Consequently, it

is likely that this product may be considered as a lower

risk substitute for factory-made cigarettes. In addition,

people report buying them to help quit smoking, to re-

duce cigarette consumption and to relieve tobacco with-

drawal symptoms due to workplace smoking restrictions

[9]. Besides delivering nicotine to the lung, e-cigarettes

may also provide a coping mechanism for conditioned

smoking cues by replacing some of the rituals associated

with smoking gestures (e.g. hand-to-mouth action of

smoking). For this reason, e-cigarettes may help smokers

to remain abstinent during their quit attempt. To date

there is no formal demonstrations supporting the efficacy

of these devices in smoking cessation for people suffer-

ing from depressi on.

Here, we report for the first time objective measures of

smoking cessation in two heavy smokers, suffering from

depression, who experiment the e-cigarette.

2. Case Report

In this case series we describe two heavy smokers with

an established history of depression who have been re-

petitively managed for nicotine dependence at our uni-

versity clinic for smoking cessation (Centro per la Pre-

venzione e Cura del Tabagismo—CPCT; Università di

Catania; Italy). At CPCT, smoking cessation programs

are based on an adaptation from the Clinical Practice

Guideline on Smoking Cessation of the US Department

of Health and Human Services [5] and have been de-

scribed previously in detail [15]. Staff at CPCT includes

a dedicated team of clinical psychologists, psychiatrists,

physicians, and nurses with at least 3-yr experience. De-

spite failing repeatedly our smoking cessation programs,

these two individuals were able to quit tobacco smoking

on their own by using e-cigarettes.

2.1. Patient 1

A 51-year-old engineer with a diagnosis of severe nico-

tine dependence attended our smoking cessation clinic in

April 2006. He smoked 30 cigarettes/day (44 pack/yrs)

with a significant level of nicotine dependence (Fager-

strom Test of Nicotine Dependence-FTND = 8). His eCO

reading at baseline was 25.5 ppm. A history and diagno-

sis of major depression were reported. He was subjected

to intensive treatment for nicotine dependence in April

2006 and subsequently in September 2007, July 2008 and

May 2009. On each occasion, he was prescribed with an

association of nicotine patches and bupropion and he was

offered smoking cessation counseling throughout the

program. Last relapse was noted on June 2009.

During a routine telephon e follow-up in January 2010,

he reported having quitted smoking on its own after tak-

ing up an e-cigarette. He was then invited to call at our

clinic to collect more details and for further investiga-

tions. He told us he started experimenting with an

e-cigarette (loaded with high nicotine concentration: 7.2

mg nicotine/cartridge) in August 2009. A few weeks later,

he was able to discontinued tobacco smoking completely.

He kept using his e-cigarette for another couple of

months before stopping using the e-cigarette as well.

Abstinence from tobacco smoking was then objectively

assessed by measuring the concentration of exhaled

breath carbon monoxide concentration (eCO); the meas-

ured eCO value was within the normal range (eCO = 4

ppm). He has been quitting tobacco smoking for ap-

proximately six months with no reported lapse/relapse

during this period of time. The e-cigarette was well tol-

erated with no reported adverse effects.

2.2. Patient 2

A 50-year-old housewife with a diagnosis of severe nico-

tine dependence attended our smoking cessation clinic in

June 2007. She smoked 20 - 30 cigarettes/day (29 pack/yrs)

with a significant level of nicotine dependence (FTND =

8). Her eCO reading at baseline was 19.8 ppm. A history

and diagnosis of major depression were reported. She

was treated for nicotine dependence at our clinic in June

2007 and subsequently in October 2007 and January

2009. On each occasion, she was prescribed with an as-

sociation of nicotine patches and bupropion and she was

offered smoking cessation counseling throughout the pro-

gram. Last relapse was not ed on February 2009.

During a routine telephon e follow-up in January 2010,

she reported having quitted smoking on her own after

taking up an e-cigarette. She was then invited to attend

for a follow-up visit at our clinic, during which absti-

nence was reviewed objectively by measuring the con-

centration of eCO. She told us she started experimenting

with an e-cigarette (loaded with high nicotine concentra-

tion: 7.2 mg nicotine/cartridge) in April 2009. Three

months later, she was able to discontinue tobacco smok-

ing completely. She kept using the e-cigarette with high

nicotine concentration for another month before switch-

ing to mentholated cartridges, which she now uses fre-

quently during social events. Abstinence from tobacco

smoking was confirmed objectively by the very low lev-

els of eCO (eCO = 2 ppm). She has been quitting tobacco

smoking for approximately seven months with no re-

ported lapse/relapse during this period of time. Overall,

the e-cigarette was well tolerated with occasional dry

Smoking Cessation with E-Cigarettes in Smokers with a Documented History of Depression and Recurr ing Relapses 283

cough being reported.

3. Discussion

The most important message from this case series is that

these individuals were able to quit and to remain absti-

nent for at least 6 months after taking up an electronic

cigarette. This is the first time that objective measures of

smoking cessation are reported in smokers, suffering

from depression, who quit after experimenting with the

e-cigarette. This is quite outstanding in consideration of

the fact that this result was accomplished by highly ad-

dicted smokers who repeatedly failed professional

smoking cessation assistance without the support of rec-

ommended nicotine dependence treatments and smoking

cessation counselling.

The remarkable success stories of these two smokers,

suffering from depression, require justification. The

widely acknowledged beneficial role of pharmacotherapy

in smoking cessation is likely to be du e to their ability to

address the physical component of tobacco dependence.

However, taking pills or patch es for nicotine addiction is

unlikely to resolve the psychological components (cogni-

tive, social and behavioural) associated with tobacco

dependence. As a matter of fact smoking is much more

than the addicting effect of nicotine; the smoking habit is

also the rituals that each smoker associates with his/her

habit [6]. For example, smoking gestures (e.g. the tactile

sensations of the cigarette and other sensations associated

with smoking gestures) can play an important part in

tobacco addiction as they are usually performed in a pre-

dictable, ritualistic manner that act to signal a mental

context shift. When the smoker stops smoking, those

rituals are no longer there, but the need for the ritual still

exists and this is an important cause of relapse. Smoking

cessation products cannot replace the rituals associated

with the act of smoking. Counselling for smoking cessa-

tion is intended to help smokers in coping with this im-

portant aspect of their life by implementing personalized

replacement rituals, but even counselling for smoking

cessation lacks high levels of efficacy.

Therefore, it is likely that th e smokers described in our

case series coped successfully with the psychological

components associated with their tobacco dependence by

using a device resembling a cigarette, which—although

being mainly designed for the purpose of nicotine deliv-

ery to the respiratory system—it has the additional ad-

vantage of being a valid substitute for the tactile sen sat io ns

of the cigarette and other sensations associated with

smoki ng g es tures.

Although the present findings cannot be generalized,

high quit rates would be desirable in a population that

generally respond poorly to smoking cessation efforts

like smokers suffering from depression. Larger con-

trolled studies are needed to confirm this interesting

findings, particularly for those smokers for whom han-

dling and manipulation of their cigarettes play an impor-

tant part of the ritual of smoking.

4. Acknowledgements

Riccardo Polosa is full Professor of Internal Medicine

and he is supported by the University of Catania, Italy.

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