Can electronic cigarettes or medication help smokers quit smoking? Dena Rashed finds out All smokers will be intrigued by the advertisements promising them they can smoke anywhere, as those hanging next to cigarette packs at petrol stations in Cairo do. Featuring a woman wearing dark lipstick and puffing what appears to be smoke, after further enquiry it turns out that the "smoke" is not regular cigarette smoke. A salesperson gets out a small black box and demonstrates the "electronic cigarette" or e- cig. Does it sell? Apparently so. The e-cig looks like a real cigarette, but it is made of steel, is battery operated, has replaceable nicotine filters and comes in different flavours. The user inhales nicotine vaporised in the device, and only harmless smoke emerges from it. The price is quite hefty at LE1,000, though still cheaper than the LE1,600 it used to cost, and, while the e-cig was invented in China in 2004, it has now hit the Egyptian market and can be found at petrol stations and quite a few tobacco stores. It has also become a topic of conversation, with people asking each other whether they have used it, or whether they intend to do so. The appeal of the e-cig lies not just in the idea of smoking without fire, but also in the device's promise that it offers the user a healthy mode of smoking. However, medical circles are still arguing about whether the e-cig is as safe as it claims to be, with the WHO in Egypt recently issuing a warning against it. "We are concerned about the matter, and so is the Egyptian Ministry of Health," said Fatima El-Awa, WHO regional advisor, in an interview with Al-Ahram Weekly. "We have given our opinion to countries in the region, and as a result Saudi Arabia has already prohibited the sale of the electronic cigarette, and Bahrain has set restrictions on its purchase," she says. In El-Awa's view, the e-cig is not healthy. "This product is being promoted with the claim that it is an effective measure to quit smoking, or as a safe method of smoking because it does not expose others to the danger of secondhand smoke," she says. "Yet, it has not been scientifically studied." According to El-Awa, research has not been done to identify possible hazards of the e-cig. Although it is being promoted as a tobacco product, it is actually a pharmaceutical product, she says, as it contains nicotine, which is a drug. If the e-cig is considered to be a pharmaceutical product, according to the WHO, then it should be subject to pharmaceutical requirements and standards, which include rigorous testing. If the e-cig is considered to be a tobacco product, then the requirements stated in the WHO Framework Convention on Tobacco Control should be observed. Either way, the e-cig's status is ambiguous, though some users still take refuge in the e-cig because they believe it does them no harm and does not pose a health risk to others. Mustafa (not his real name) has been a smoker for the past 30 years, and he has no intention of quitting. He has used the e-cig as an alternative to smoking cigarettes in enclosed spaces where smoking is otherwise prohibited. He also believes that the e-cig has allowed him to reduce his cigarette consumption. "I get a bit tense when I am not smoking, so the e-cig gives me the feeling of a real cigarette, especially at the office, the airport, or at cinemas," Mustafa says. He has also drawn the attention of others to the e-cig, especially those who have never heard of it, but says that it still remains misunderstood. "I have had people arguing with me, and starting to cough the moment I use it, because they imagine that any smoke coming out of the device is real smoke," he says. In his view, the e-cig is a good idea, since inhaling the nicotine of a cigarette without the tar and the rest of the tobacco smoke is healthier than smoking a real cigarette. Nevertheless, Mustafa is aware that even e-cigs have to be smoked with caution. "I take a couple of puffs every half an hour," he says, "and I never use the device if I think it is in danger of overheating." The price is high compared to regular cigarettes at around $10 for five filters. Another user, also the importer of one brand of e-cig into Egypt, is Khaled Zaazaa, who came across the product during a trip to the US. Zaazaa describes himself as a genuine smoker who smokes out of habit not out of need, and he says that he has no intention of quitting. When he came across the e-cig, Zaazaa says, he thought he had found a way of decreasing the number of cigarettes he smoked each day. Despite the fact that the e-cig is still a controversial product, Zaazaa explains that he has the authorisation to import it into Egypt. "The product has been sold in the UK and the US for the past two years," he says, "and in Egypt it is not listed as being forbidden for importation." Nevertheless, the US Food and Drug Administration (FDA), the federal body charged with assuring the safety of foods and medicines, announced last month that "laboratory analysis of electronic cigarette samples has found that they contain carcinogens and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze." Another problem underlined by the FDA is that e-cigs have not been formally submitted for testing, so "the agency has no way of knowing, except for the limited testing it has performed, the levels of nicotine or the amounts or kinds of other chemicals that the various brands of these products deliver to the user." As a result, the FDA has issued alerts against e- cigs in the US. For its part, the Electronic Cigarette Association (ECA), the industry body, has contested the FDA's judgement, and in material on its Website states that "the FDA's analysis is too narrow to reach any valid and reliable conclusions, and ignores the continued efforts by member companies to ensure that their products include health warnings and only market products as an alternative to long-term adult smokers." The ECA also argues that tobacco smoke can contain some 4,000 ingredients, including arsenic and carbon monoxide, as well as dozens of other potentially cancer- causing chemicals. As Zaazaa puts it, "I don't see the harm in the e-cig compared to normal cigarettes. If normal cigarettes do harm, then e-cigs probably do only one per cent of the harm that they do, since they do not contain paper, tar or carbon like regular cigarettes." Nevertheless, according to the man in charge of trying to stop Egyptians from smoking, Mohamed Mehrez, director of the Tobacco Control Department at the Ministry of Health, smoking is still smoking whatever form it takes. "We take the WHO and FDA recommendations very seriously," Mehrez says, "and they have shown that these products negatively affect users' health, as well as the health of passive smokers around them." The problem, as Mehrez sees it, is that e-cigs are creating a new generation of smokers. "Nicotine is addictive, so if a young man buys the product believing it is healthy at a cost of LE1,000 and then cannot afford the price of the filters, buying regular cigarettes becomes the cheaper and easier option. As a result, another smoker joins the existing 24 million smokers in Egypt." Since cigarettes continue to be sold freely in Egypt, the mission of Mehrez's department is all the more difficult. "We care about providing people with the right information to quit, because we care about people's health," he says. "This means that we can't say less damage is better than more damage. The real answer is quitting." Mehrez believes that the media should play a greater role in raising public awareness of the hazards of smoking, in addition to the obligatory written and pictorial warnings that appear on all cigarette packs sold in Egypt and the existing governmental and non-governmental anti-smoking campaigns. Further information on the e-cig is expected from the Ministry of Health in November. In the meantime, Mehrez says that the ministry intends to take legal action to try to prevent the import and sale of e-cigs until tests can be carried out. However, the fight against tobacco smoking is likely to be a long one, especially because for many smokers, smoking is an activity, a hobby and a friend. While there are some smokers who won't stop till their last breath, others try to quit every once in a while, even living smoke free for a time and then falling back into the habit. While some smokers have tried e-cigs as a way of decreasing the number of cigarettes they smoke, others have opted for a more medical solution. Zeinab Abdel-Razak, for example, a reporter, was a smoker for 15 years, yet wanted to quit at heart. She is keen on sharing her experience of quitting with others, because she wants all smokers to know that it is possible to quit. "I started smoking for fun with friends, but then my whole world started to revolve around smoking. I could not write or work without a cigarette in my hand, and in Ramadan I felt desperate because I could not focus while fasting. I was desperate to quit." Her need to live without smoking intensified when she was diagnosed with an abnormal heart beat. Although she was convinced that smoking was bad for her skin, hair and overall health, she still could not quit because "the cigarette was like a friend to me." Abdel-Razak then heard of an older relative who had suffered from a stroke and had used drugs to help him quit. Abdel-Razak, too, began to believe that this was her only way out. "I took the anti-smoking drug for three and a half months. It worked, and I have not smoked one cigarette for the past five months," she says. "All I think about today is the fact that if I smoke again I will fall sick again." She says that she suffered side effects from the medication, including depression, nausea and loss of focus, and she even had a car accident, which she believes was brought on by the effects of the anti- smoking medication. Nevertheless, Abdel-Razak says, "I did not care about the side effects, as they were a price I was willing to pay to help me quit." She admits that she did not take the medication under proper medical supervision, however, something which Mehrez believes could have saved her from the side effects she suffered. "Any drug should be taken under the supervision of a doctor," he says, "because a doctor can prescribe the correct dosage and control any side effects." The drug Abdel-Razak took is also expensive at LE1,600 a course, and it has to be specially ordered from pharmacies. While some smokers are prepared to go to considerable trouble and expense in order to quit smoking, others are able to do so using just will power. Ahmed Abul-Enein, an engineer, was a smoker for 12 years, having started smoking out of curiosity and then finding that he became a heavy smoker. Although he changed to a lighter brand of cigarettes, he never saw himself quitting or even trying to quit. However, one day, Abul-Enein says, "I woke up, had nothing to do on an empty weekend, and the thought just hit me: why not quit smoking? So I did." Following his decision to quit, Abul-Enein says that he slept better and felt generally better overall, but still felt he was missing something, as he was used to smoking while driving, drinking coffee and during the day at work. Stopping smoking for him was like losing a source of entertainment or a companion. One day, when faced with a rough day at work he reached for a cigarette and found his resolve literally going up in smoke. Today, Abul-Enein says that he is smoking again and has even thought about purchasing an e-cig machine. However, "the idea of quitting is not farfetched anymore, because I know that I can do it and really quit if I put my mind to it," he says. Despite the different opinions of Mehrez and Zaazaa regarding the e-cig, one thing both agree upon is that nothing will help a smoker quit if he or she does not really want to do so.
