E-Cigarettes: The Jury Is Out

By Heather Stringer

The advertisement features an attractive brunette fes­tooned with trendy bracelets and earrings; she holds a black e-cigarette between her fingers. The tagline: “Wel­come to the all new Vapor Couture: Fash­ion. Meet Vapor.”

In the past several years, similar adver­tisements have trickled into television, print, and online media, promoting the growing industry of e-cigarettes as a fash­ionable accessory—and a healthier alterna­tive to traditional cigarettes. But beneath the airbrushed models and clever cam­paigns, an intense debate is broiling about whether these new products deliver what they promise.

For tobacco smokers eager to cut down or quit, the battery-powered vaporizer may seem an ideal solu­tion. E-cigarettes simulate tobacco smoking in many ways—without the 7,000 chemicals, including at least 70 known carcinogens.1 The heating element, or atomizer, va­porizes a liquid solution containing nicotine, a flavoring of some kind, vegetable glycerin, and propylene glycol—a chemical generally recog­nized as safe by the US Food and Drug Administration.

But while advocates of e-cigs claim that this new product is less harmful than the tobacco variety, many medical professionals are still hesitant to say that smokeless cigarettes are actually safe. While nicotine in itself is not carcinogen­ic, there are concerns about other potential health issues related to “vaping,” such as whether the sleek, new technology will lure youth into a nicotine addiction that eventually becomes a pathway to a tobacco cig­arette habit. Opponents argue that decades of efforts to educate the public about the risks of smoking will be eroded if companies are al­lowed to continue marketing e-cigs as a healthy alternative to tobacco smoking.

Although studies are starting to show evidence documenting both the potential dangers and the ben­efits of e-cigarettes, most experts agree that more information is needed.

“I think the public is getting a very confusing message,” says Jon Ebbert, MD, a clinician in the Nic­otine Dependence Center at the Mayo Clinic in Minnesota. “Every­one is trying to figure out how this is going to play out. This new tech­nology could eventually go by the wayside, or it could gain legitimacy through data as a method of safe treatment for smoking cessation. I am open to the fact that it could be a safe treatment, but at this point I am not going to give it to any pa­tients until it is shown to be safe and effective.”

Humble Beginnings

The e-cigarette was first invent­ed in 2003 in Beijing, China, by a 52-year-old pharmacist named Hon Lik, whose father was a heavy smoker who died of lung cancer. E-cigarettes were introduced to the United States seven years ago, and since then sales have expanded to a $1.5 billion industry in this country.

One of the most compelling ar­guments for proponents of the new technology is that nicotine is not a carcinogen, and e-cigs are a safe way to deliver nicotine. Physicians like Tara Narula, MD, FACC, as­sociate director of the cardiac care unit at Lenox Hill Hospital in New York, are not convinced.

“Nicotine can raise the blood pressure and heart rate and in­crease the workload on the heart,” Dr. Narula says. “It constricts blood vessels to the heart and also has the potential to make blood more ‘sticky,’ or hypercoagulable. This can increase the risk that a clot will form in the arteries and eventually cause a heart attack or stroke.”

Smoking can be particularly un­safe for women who are over 35 and taking birth control pills, Dr. Na­rula says. This form of contracep­tion may increase the risk of a heart attack, and smoking is another risk factor for a cardiac event. Many doctors agree with the American College of Obstetricians and Gy­necologists’ recommendation that birth control pills should not be prescribed to women who are over 35 and smoke, due to the increased risk of heart attack, but there are no standards yet for prescribing the pill for women who use e-cigarettes.

The nicotine in the liquid for e-cigs may also be dangerous for chil­dren who come into contact with it, explains Robb Bassett, DO, a medical toxicologist in the Poison Control Center at Children’s Hos­pital of Philadelphia. “In that very small vial, the concentration of nicotine is exceedingly high,” he ex­plains. “I could easily see how chil­dren who stumble onto a vial could swallow much more nicotine than they could ingest from a tobacco cigarette. These chemicals can be so toxic to the body that acute ex­posure can still be lethal. If parents understand this reality, hopefully they will keep these products out of reach of children.”

Potential Risks for Youth

Perhaps one of the most controver­sial subjects surrounding e-ciga­rette use is whether it will become a gateway to tobacco smoking for youth. According to the 2011 and 2012 National Youth Tobacco Sur­vey, the number of high school students who had tried an e-ciga­rette doubled from 4.7 percent to 10 percent between 2011 and 2012.2 Roughly 80 percent of high school e-cigarette users also smoke con­ventional cigarettes, according to the survey.

The “dual use” of both varieties of cigarettes concerns researchers such as Stanton Glantz, PhD, who have studied smoking patterns among adolescents in the United States. Dr. Glantz, director of the Center for Tobacco Control Research and Education at the University of Cali­fornia, San Francisco, analyzed data from the National Youth Tobacco Survey and published his findings in March 2014 in JAMA Pediatrics.3

“To me the most serious thing we found in our study was that among kids who had experimented with tobacco cigarettes, the odds of be­coming a regular tobacco cigarette smoker increase about eight times among kids who use e-cigarettes compared with those who don’t,” explains Dr. Glantz. “E-cigarettes seem to move from experimenta­tion to regular tobacco cigarette use among these kids. Kids who use e-cigarettes are also much less likely to have stopped smoking tobacco cigarettes.”

Personal Stories Provide Insight

Although many physicians may be wary about endorsing e-cigarettes at this point, proponents like Maria Verven speak to positive personal experiences. Maria, 58, is passionate about smoking cessation because she grew up with continual expo­sure to secondhand smoke from parents who both lit up regularly. She was deeply disappointed when her 21-year-old daughter took up tobacco cigarette smoking three years ago. “What tends to happen is that young women start smok­ing as a social activity,” Maria says. “My daughter felt pressured because people would have a smoke during a break at work, and pretty soon she was addicted.”

After three years of tobacco smoking, her daughter was eager to quit—but repeated attempts to use the nicotine patch or gum did not help her kick the habit. When a friend introduced Maria to e-cigs, she immediately thought of her daughter. Maria purchased an e-cigarette kit, and within one month her daughter successfully quit. She now abstains from both vaping and smoking.

Witnessing her daughter’s journey convinced Maria that e-cigarettes could help other women struggling to quit smoking. In 2012 she launched Vaping Vamps, an online brand for women that sells e-cigs in five flavors with four different levels of nico­tine—18, 12, 6, and 0 milligrams/mil­liliter. The website promotes a “safer alternative to smoking” and a more effective way to quit than the nico­tine patch.

A study published in September 2014 in the journal Addiction lends credence to Maria’s personal experi­ence. Researchers interviewed about 6,000 smokers who had tried to quit on their own, and they found that about one-fifth of those using e-cig­arettes at the time of the survey had stopped smoking tobacco cigarettes, compared with only one-tenth of the people who had used nicotine patch­es and gum.4

According to the Centers for Dis­ease Control and Prevention, an estimated 42.1 million Americans smoke cigarettes, and smoking ac­counts for 480,000 deaths per year. Gilbert Ross, MD, executive direc­tor of the American Council on Sci­ence and Health, is adamant that e-cigarettes have many advantages over traditional smoking-cessation aids such as the nicotine patch. “It is very difficult to quit smoking, and only about 5 to 10 percent of people succeed,” says Dr. Ross. “The rav­ages of cigarette smoking are the most important preventable pub­lic health problem we face in this country and in the Western world. One way to get cigarette smoking to decline is to encourage the use of nicotine products that are low-risk, which would include e-cigarettes.”

“You can’t expect the nicotine patch to mimic the sensations of pulling out the cigarette, lighting it, the hand to mouth experience, and then inhaling,” Dr. Ross says. “The patch also releases nicotine slowly throughout the day, which does not deliver the same punch as a ciga­rette, which is much more of a peak-and-valley experience of nicotine.”

Patients Want To Know

In the past few years, Susan Peck—a women’s health nurse practitioner in New Jersey—has seen an increase in the number of patients who are asking about e-cigarettes as a smok­ing-cessation strategy.

“Many patients are concerned about the side effects of oral medi­cation to aid cessation, and e-cigarettes have the advantage of having the same look and feel as a traditional cigarette, which can satisfy the craving for emotional and behavioral stimuli,” says Peck, who works at Rutgers Robert Wood Johnson Medical School. “I try to educate patients that although e-cigarettes are likely safer than to­bacco cigarettes, there are still a lot of unknowns.”

A handful of her patients have chosen e-cigarettes as a strategy and have successfully quit smoking, but Peck believes that this may be linked more to their commitment to quitting than to the particular method of cessation.

“I don’t think the e-cigarette is the only reason these women were successful,” Peck says. “It is not easy to quit smoking, and they have to be ready for that step mentally and emotionally. I think it is the combi­nation of the e-cigarette itself and the motivation to be a nonsmoker.”

A Personal Call

E-cigarettes are not yet regulated by the US Food and Drug Administra­tion (FDA)—which means consum­ers are judging for themselves the relative safety of vaping. On August 25, 2014, the American Heart Asso­ciation published policy recommen­dations that underscored the urgen­cy to implement stricter guidelines related to e-cigarettes, such as clean indoor air laws, taxation, market­ing, and preventing youth access.

In time, studies will reveal whether smokeless cigarettes are the best hope for the millions of smokers who try to quit every year and fail. In the meantime Peck encourages consumers—and spe­cifically women—to be thoughtful before making a choice. “There is a lot of marketing going on right now that is targeting women,” she says. “Companies are turning e-cigarettes into fashion accessories that come in beautiful packaging and can be used as a necklace or bracelet.” The mar­keting trend is especially concerning, Peck says, for its potential to entice younger women to smoke: “This is worrisome to me for late adoles­cents or young women because an e-cigarette is more than a fashion ac­cessory; it’s a product that contains nicotine.”


 Timeline of Events In E-Cigarette History

2003 E-cigarette is first developed in China by Hon Lik.

2003-2006 E-cigarettes first marketed in the United States online and in kiosks in shopping malls.

2009 March: The FDA notifies e-cigarette company Smok­ing Everywhere that its shipments have been refused entry into the United States. The FDA states that e-cigs “appear to be a combination drug-device­product” that requires preapproval, registration, and listing with the FDA. April: Smoking Everywhere files a federal complaint seeking an injunction against the FDA about the ban on e-cigarette importation. The complaint contends that e-cigarettes are a tobacco product, not a drug-delivery product.

2010 January: A federal judge rules that the FDA cannot stop the e-cig shipments, saying that the agency overstepped its authority. December: A federal appeals court rules that e-cigarettes should be regulated as tobacco products by the FDA rather than as drug-delivery devices.

2011 The FDA announces plans to regulate e-cigarettes as tobacco products.

2014 The FDA issues proposed guidelines for electronic cigarettes.


 Proposed FDA Guidelines For E-Cigs

Under the proposed rule, makers of e-cigarettes would be required to do the following:

  • Register with the FDA and report product and ingredient lists
  • Market new tobacco products only after FDA review
  • Make direct and implied claims of reduced risk only if the FDA confirms that scientific evidence supports the claim that marketing the product will benefit the public as a whole
  • Not distribute free samples
  • Follow minimum age and identification restrictions to prevent sales to underage youth
  • Follow requirements to list health warnings
  • Not sell product in vending machines, unless in a facility that never admits youth

Source: US Food and Drug Administration


 E-Cigarette Sales by Year


References

  1. How Tobacco Smoke Causes Disease. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/tobacco/data_statistics/ sgr/2010/pdfs/key-findings.pdf. Accessed October 3, 2014.
  2. Notes from the Field: Electronic Cigarette Use among Middle and High School Students—United States, 2011–2012. Centers for Disease Control and Prevention website. Available at: http://www.cdc. gov/mmwr/preview/mmwrhtml/mm6235a6.htm. Accessed October 3, 2014.
  3. E-Cigarette Use by Adolescents Associated with Higher Odds of Smoking. JAMA Network website. Available at: http://media.jamanetwork.com/news-item/e-cigarette-use-by-adolescents-associated-with-higher-odds-of-smoking. Accessed October 3, 2014.
  4. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: A cross-sectional population study. Addiction. 2014;109(9):1531-40. doi: 10.1111/ add.12623.