Video interview and article ; Dr Riccardo Polosa
Dr. Riccardo Polosa, MD, PhD, is the Director of the Institute for Internal Medicine and Clinical Immunology of the University of Catania in Italy. He is also in charge of the University’s Centre for Tobacco Research (CPCT), and Honorary Professor of Medicine at Southampton University (UK). He is author of more than 200 peer reviewed articles and books mainly covering respiratory medicine, clinical immunology, and tobacco addiction.
On top of his academic work, he holds the post of director of Lega Italiana Anti Fumo (LIAF), the Italian Anti-Smoking League.
Polosa was the lead scientist in a clinical trial on e-cigarettes with positive outcomes.
Smoking Cessation with E-Cigarettes in Smokers
with a Documented History of Depression and
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.
Received February 24th, 2011; revised April 16th, 2011; accepted April 30th, 2011.
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
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 , 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  or medicate
depressed mood . Until recent years, the belief that a
history of depression greatly decreases the likelihood of
quitting smoking has b een widely promoted . 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 . Predictably,
smokers reporting higher levels of negative mood and
depressive symptoms were less likely to quit than were
smokers with less mood disturbance . 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. 
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 . 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 .
Smoking Cessation with E-Cigarettes in Smokers with a Documented History of Depression and Recurr ing Relapses
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 . 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
. 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  and have been de-
scribed previously in detail . 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
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Smoking Cessation with E-Cigarettes in Smokers with a Documented History of Depression and Recurr ing Relapses 283
cough being reported.
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 assistancewithout the support of rec-
ommended nicotine dependence treatments and smoking
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 . 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.
Riccardo Polosa is full Professor of Internal Medicine
and he is supported by the University of Catania, Italy.
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