LETTER TO THE EDITOR
Hidden risks of electronic cigarettes to patients undergoing
Received: 9 February 2014 /Accepted: 20 February 2014 / Published online: 11 March 2014
Springer-Verlag Berlin Heidelberg 2014
In recent years, we have noted an increase in the use of
electronic cigarettes (e-cigarettes) within our operative cohort.
In 2013, an estimated 1.3 million individuals were using e-
cigarettes in the UK .
E-cigarettes are battery-operated devices, which deliver a
non-tobacco-derived warm vaporised smokeless stream of
nicotine to the user. Although e-cigarettes are not explicitly
marketed as a healthier alternative to conventional cigarettes,
the public may be forgiven for drawing this conclusion. Nic-
otine replacement therapies, such as gum and patches, are
classed as drugs and therefore regulated by the Medicines
and Healthcare Products Regulatory Agency (MHRA). Al-
though e-cigarettes are due to be regulated in the UK by the
MHRA in 2016 , they are not currently classed as a drug or
tobacco product, sanctioning an erroneous perception of in-
nocuousness by both the public and clinician alike.
While e-cigarettes have not been proven to have deleteri-
ous effects, no long-term follow-up of these largely unregu-
lated devices has yet been conducted. Studies have identified
widely varying constituents, both within and between the
many available brands [1, 5]. Despite an absence of tobacco,
carcinogenic agents, formaldehyde, and diethylene glycol
(anti-freeze) have been isolated in the emitted vapours [1, 5].
The delivery of nicotine by these devices, a drug known to
compromise wound healing , shows that the e-cigarette is
not without implication to the patient undergoing plastic sur-
gery. Analysis of e-cigarette vapour shows a level of nicotine
at least comparable to conventional cigarettes . Indeed, the
potential for nicotine delivery by these devices may even be
higher than the conventional cigarette, with greater social
acceptability allowing users to circumvent existing smoking
bans in public places and their less self-limiting nature facil-
itating a greater number of inhalations per smoking episode.
Such is the permissive attitude toward these devices that we
have even observed inpatients to be using them in the imme-
diate post-operative period, where smoking of conventional
cigarettes would otherwise be impossible.
That patients are able to reach for these devices as noncha-
lantly as for a hot drink should be a cause for alarm to the
plastic surgeon. Of perhaps equal concern is that we as trusted
care providers may have been caught off guard by an old
enemy, dressed in new clothing.
Conflict of interest We declare no conflict of interest.
Ethical standards The manuscript does not contain clinical studies or
1. Cobb NK, Byron J, Abrams DB et al (2010) Novel nicotine delivery
systems and public health: the rise of the ‘e-cigarette’.AmJPublic
2. Flouris AD, Chorti MS, Poulianiti KP et al (2013) Acute impact of
active and passive electronic cigarette smoking on serum cotinine and
lung function. Inhal Toxicol 25(2):91–101
3. Krueger JK, Rohrich RJ (2001) Clearing the smoke: the scientific
rationale for tobacco abstention with plastic surgery. Plast Reconstr
J. Jeevaratnam (*)
Department of Plastic Surgery, Queen Victoria Hospital,
East Grinstead RH19 3DZ, UK
Eur J Plast Surg (2014) 37:457–458