Nicotine and E-Cigarettes: What Patients Should Know

Introduction

My name is William Conway, MD. I am a general internist with a subspecialty in addiction medicine. I have practiced addiction medicine since 2012. My current addiction treatment practice is Suboxone+Primary Care™, located in Nashville. My current practice of general internal medicine is Nashville Concierge Medicines.

That smoking produces death, disability, and suffering is well known. As a general internist, I have repeatedly seen and treated serious diseases produced by smoking. As a specialist in addiction medicine, I have many patients who chose smoking cessation, or abstinence. Abstinence is always the goal in patient care for all patients with addictions. This is true with all substances, including tobacco.

With full knowledge of the consequences, many of my patients still continue to smoke, choosing to be nicotine dependent. For many reasons from pleasure to habit, to identity, to avoidance of withdrawal, they continue to smoke cigarettes. This is legal. I dedicate the rest of this blog to those who continue to smoke, because they also deserve care from evidence based medical guidance focused upon safety and comfort.

All medical care should be individualized. These consensus principles should be reviewed by the physician of your choice.

 

Executive Summary

  1. Nicotine is highly addictive and can therefore cause withdrawal symptoms that disrupt daily life and productivity.
  2. E-cigarettes, while not risk free, expose users to fewer toxins than combustible tobacco, and can help manage cravings.
  3. Daily use of nicotine patches and gum can make it easier to manage cravings and feel more comfortable throughout the day.
  4. Effective treatments for quitting include varenicline, bupropion, and nicotine replacement therapy (which includes patches and gum).
  5. The newer nicotine salts in e-cigarettes deliver higher doses of nicotine more smoothly, making them popular but also more addictive.
  6. When you decide to quit combustible tobacco or e-cigarettes, our current treatments can help walk you through withdrawal more comfortably.

 

Why Nicotine Use Matters

  • Addictive potential: Nicotine is one of the most addictive substances known.
  • Daily disruption: Withdrawal symptoms can interfere with productivity and overall well-being.
  • Health risks: Cigarette smoking causes cancer, heart disease, lung disease, and numerous other conditions.
  • Evolving products: E-cigarettes and nicotine salts have changed how people consume nicotine. These developments carry both potential benefits and a variety of risks.

 

Active Management of Your Daily Nicotine Levels

For patients not yet ready to quit, managing withdrawal symptoms can make daily life more comfortable and help with work productivity. The key to managing your comfort as an active nicotine user is to understand that nicotine levels drop quickly. You need a cigarette or vape every one or two hours to maintain your nicotine levels, and therefore your comfort. Smoking cigarettes has been made very difficult in corporate and social settings. Getting a smoke break every 1-2 hours during a workday is both difficult and makes you subject to scrutiny.

 

Cigarettes and E-Cigarettes Deliver Nicotine in Similar Patterns

Both cigarettes and e-cigarettes provide a rapid rise in nicotine levels, followed by a sharp decline. This cycle explains the need for frequent nicotine use to avoid withdrawal symptoms.

Using a Daily Nicotine Patch Can Keep You More Comfortable

A nicotine patch provides a steady baseline dose of nicotine throughout the day. This can keep you more comfortable. It can also allow for fewer cigarette or vape breaks at work or in social situations.

 

Using Nicotine Gum Can Also Provide Relief from Withdrawal Symptoms

Chewing nicotine gum can provide relief when cravings break through the patch. Chewing gum causes nicotine levels to peak more slowly than vaping, but it also results in a steadier nicotine level. This can be helpful for managing cravings without the “rush” of smoking or vaping.

Here’s the nicotine concentration curve for gum (4 mg every 2 hours):

  • Slower rise: It takes about 20-30 minutes to reach peak levels.
  • Lower peak: It tops out around 8-10 ng/ml, much lower than smoking or vaping.
  • Gentle decline: Levels taper more smoothly, without sharp drops.

Please note that consistent use of nicotine gum promises significant relief from withdrawal. With consistent use of gum every  two hours, your nicotine level rises.

 

Our Evidence-Based Treatments for Quitting Are Safe, Effective, Inexpensive, and Well-Tolerated

When you are ready to stop nicotine completely, several safe and effective options are available to you. These include:

  • Varenicline, which reduces cravings.
  • Nicotine replacement therapy (such as patches and gum), which helps reduce withdrawal symptoms.
  • Bupropion, an antidepressant that can reduce nicotine cravings and withdrawal symptoms.

Each of these treatments is most effective when paired with ongoing support and follow-up care. As an addiction specialist, I have years of experience helping patients on this journey.

 

Nicotine Salts: A Game Changer in E-Cigarettes

Nicotine is found naturally in tobacco leaves. Naturally occurring nicotine is alkaline, which can cause throat irritation when smoked. Manufacturers of e-liquids began adding an organic acid (usually benzoic acid) to make the nicotine easier to inhale. This also made vaping easier on the throat, creating a smoother inhalation experience for e-cigarette users as compared to the traditional “freebase” form of nicotine used in combustible cigarettes. The decreased bitterness also allowed for higher nicotine concentrations. The higher nicotine concentrations resulted in a longer-lasting sense of satisfaction.

Nicotine salts were widely adopted after the e-cigarette company JUUL introduced them in 2015. The result was a significant jump in the popularity of e-cigarettes, especially among adolescents and young adults. There was also a considerable jump in new smokers. This commercial success was also a public health concern, especially for adolescents.

Younger users especially were drawn to the combination of high levels of nicotine with smooth taste and a discreet form of delivery. Nicotine salts also vaporize at lower temperatures than traditional nicotine. This makes them especially suitable for smaller and lower-powered vaping devices as well as the “starter kits” favored by younger users.

 

Why Nicotine Salts Matter Clinically

  • Smoother inhalation: Less throat irritation compared to traditional “freebase” nicotine makes it easier to consume higher doses of nicotine.
  • Higher nicotine delivery: E-liquids can now contain much higher nicotine concentrations (up to 25–60 mg/mL vs. 3–18 mg/mL in older e-liquids), while increasing palatability.
  • Faster absorption: Nicotine salts produce a rapid, cigarette-like “hit” that repeatedly reinforces dependence.
  • Ease of use: The increased concentrations of e-liquids containing nicotine salts makes them both cost-effective and more portable than older e-liquids.
  • Increased addiction risk: Because nicotine salts enter the bloodstream more quickly and in higher concentrations, they increase the potential for dependence. The brain experiences the reinforcing “rush” that resembles the effect of smoking traditional cigarettes.
  • Effects on younger users: From a public health perspective, the increased risk of addiction is particularly concerning for adolescents, whose developing brains are more susceptible to forming addiction pathways.

For these reasons, many people in Nashville using nicotine salts are consuming far more nicotine than they realize. This will make withdrawal symptoms more intense and may require a multi-pronged approach to quitting. This approach is best implemented under the care of a physician who can provide an individualized treatment plan.

 

E-Cigarettes Compared with Cigarettes

Compared with combustible cigarettes, e-cigarettes contain fewer known toxins. They are therefore considered lower risk than traditional cigarettes. But even with fewer harmful chemicals, e-cigarettes are not risk-free. Even so, they may be used as part of an individualized treatment plan geared toward eventual abstinence. This plan may also include nicotine replacement therapy (such as patches and gum).

 

Conclusion

If you continue to use nicotine, you need to find ways to be comfortable. You need to be able to optimize your work in a world which makes smoking difficult. Experiencing persistent withdrawal symptoms throughout the day is disruptive. Using a variety of tools, you can reduce or eliminate your withdrawal symptoms. These tools may include nicotine patches, gum, and careful tapering of e-cigarette use. This is important as you work toward long-term abstinence. When you are ready to quit completely, our treatments work well.

Treatments like varenicline, bupropion, and structured nicotine replacement are safe, effective, and well-tolerated for many patients. E-cigarettes may carry fewer risks than cigarettes, but they are not a safe long-term solution. If you choose to use nicotine with a full understanding of its risks, you should be astute in enjoying it by minimizing withdrawal symptoms.

No nicotine product is entirely safe. Decisions about reduction or cessation should be mad with your physician.

 

📌 The Bottom Line

Abstinence from nicotine is the healthiest option. For patients not yet ready to quit, individualized care can provide comfort and stability until they are ready to take the next step.

 

CTA: If you’re struggling with nicotine dependence, I, Dr. Conway welcome you to explore treatment options with Suboxone+Primary Care™ in Nashville.

 

👉 Call 615-708-0390 | Office & Telemedicine Appointments Available

This information is for educational purposes only and does not constitute medical advice. Nicotine products, including e-cigarettes, are not FDA-approved for smoking cessation. All medical decisions should be made in consultation with a licensed Tennessee physician.