Ask An Expert: E-cigarettes and other alternative smokes

Q: “Are electronic cigarettes safe to use? What about other smoking alternatives, like herbal cigarettes and hookahs?”

Answered by Meera Jain, M.D., internal medicine physician, Providence Medical Group-Northeast, and medical director, Providence Tobacco Cessation and Prevention Program

If all of the world's smokers found a genie in a bottle, many of them would surely wish for an alternative to cigarettes that would allow them to continue enjoying their habit without the fear of cancer, addiction and all the other health risks that go along with smoking.

It's that kind of magical thinking that's fueling heavier use of e-cigarettes, herbal cigarettes and hookahs. Unfortunately, these alternatives pose many of the same health risks as traditional cigarettes – and some of them may be even worse.

Here's a summary of what we know about these smoking alternatives.


Electronic cigarettes, or e-cigarettes, convert liquid into a vapor that is inhaled. Instead of tobacco, they use a liquid form of nicotine and other flavorings. The FDA has not endorsed them, and has ruled them a tobacco product, even though they don't use tobacco.

The marketers of e-cigarettes claim that they are safe and that they help you quit smoking. Neither of these claims has any proof to support it.

Let's look at the safety claim first. The truth is, we simply don't know how safe it is to inhale vaporized nicotine. Any time you inhale something foreign into your lungs, it can damage your mouth, airways and lungs. A few years ago the FDA looked at two of the leading brands of e-cigarettes and found low levels of carcinogens in them. We also know that they pose a risk of nicotine toxicity if you inhale too much.

Another risk that you don't hear much about is the risk of fire with these products, due to the heating element and batteries. There have been several reports of burns and injuries, including one man in Florida who had an e-cigarette explode in his mouth.

What bothers me most is the claim that they can help you quit smoking. Fact: E-cigarettes are delivery devices for nicotine, which is the same highly addictive substance found in traditional cigarettes. E-cigarettes make it very easy to develop and continue a very addictive habit. To me, that's their most serious health consequence. In addition to the addictive nicotine, they mimic the surprisingly addictive hand-to-mouth motion of smoking a cigarette. A much more effective way to break both addictions is to use FDA-approved medication, whether it's bupropion (Zyban) or varenicline (Chantix), or nicotine-replacement therapies such as inhalers, patches, gums and lozenges that eliminate the hand-to-mouth habit as they help you taper off of nicotine.

Bottom line: It's not clear how safe e-cigarettes are, and it's abundantly clear that they cause, and can further, nicotine addiction. If you are thinking about trying them to help you quit smoking, a much better route is to call the Quit Line, 1-800-QUIT-NOW, and to take advantage of FDA-approved therapies.

Herbal cigarettes

The most common herbal cigarettes are clove cigarettes, which are 60 to 70 percent tobacco mixed with cloves and clove oils, plus additives and flavorings. These often are marketed as safer than traditional cigarettes, but they produce tar – one of the main cancer-causing agents of regular cigarettes. Studies show that they have the same carcinogens found in regular cigarettes. Their secondhand smoke poses risks for the people close to the smoker. And because they are mostly tobacco, they also deliver nicotine and cause nicotine addiction. So they're really no safer than traditional cigarettes at all. In fact, they may be even more dangerous, because their sweet clove smell and taste appeals to young people, who may be more likely to get addicted.

There are herbal cigarettes that don't have tobacco – just herbs – but they don't seem to be widely available. With these products, like anything that you put in your mouth and smoke, you're still burning particulate matter that produces tar, which we know is highly carcinogenic.

Bottom line: The words “herbal” and “natural” may make you think these products are safe, but they're not. They all produce tar, which causes cancer. With clove cigarettes, you also risk nicotine addiction.


Hookahs are water-cooled pipes with one or more tubes that allow several people to smoke from the same pipe. They can be used with herbs, but are most commonly used to smoke tobacco with added flavorings.

Most people think hookahs are safe, but in fact, they are worse than cigarettes. According to a shocking statistic from the World Health Organization, the average one-hour hookah session exposes you to as much smoke as a cigarette smoker would inhale from 100 cigarettes. The widespread myth is that the water in the hookah filters out the toxins, but it does not – it only cools the smoke to make it easier to inhale. You still get the cancer-causing tar and carbon monoxide. You still get the addictive nicotine. And in addition, you risk contracting herpes, hepatitis, colds, flu and other transmittable diseases when sharing the mouthpiece of the hookah with others.

Like sweet, herbal cigarettes, hookahs pose a potent threat to young people. In recent years, “hookah bars” have become very popular hangouts for the under-21 crowds, capitalizing on the bar atmosphere with flavored-tobacco menus that look just like cocktail menus to make smoking with friends seem fun.

Bottom line: Hookahs are not safe. In fact they are much worse than cigarettes, and they are enticing young people to get together to smoke. If you know people who think that hookahs are fun and safe, help them out by debunking those myths.

For all of these smoking alternatives, the old adage applies: If it sounds too good to be true, it probably is. But marketing and magical thinking are a potent combination that is driving a huge upswing in the use of alternative smoking devices. Our young people are especially at risk and need to be educated about the realities. So the next time you find yourself or someone else wishing on a genie, remind them that, when it comes to smoking, the only safe magic is to quit.

Other articles by Dr. Jain: Ask an expert: Best bets to help you quit smoking for good, Not on my watch: How to make sure your kids never become smokers. Find more Providence articles on smoking here.