Vapor and Mirrors: Are E-Cigarettes Masquerading as a Safer Alternative?
Would you like your electronic cigarette (e-cigarette) to be flavored like cherry, chocolate—or menthol? With nicotine—or without?1
Battery-powered e-cigarettes, “mimic the look and feel of smoking by vaporizing a liquid solution”2 and have been billed “as a safer, more convenient, and socially acceptable alternative to smoking tobacco cigarettes.”1 However, data on many aspects of e-cigarettes are limited or lacking: do they help people quit smoking—or do smokers simply use both? Are they a “gateway” product for adolescents? Do they contribute to risk of lung cancer?
E-cigarettes may or may not resemble a tobacco cigarette and typically contain nicotine, propylene glycol, or glycerol to produce the aerosol as well as the flavorings. They have also been found to contain potentially harmful irritants, genotoxins, and carcinogens.3,4
Since being imported from China in 2007, sales of e-cigarettes have soared to $1.7 billion, albeit still only a fraction of what tobacco rakes in.2 The United States Food and Drug Administration (FDA) sought to ban e-cigarettes as unapproved drug-delivery devices in 2008; however, manufacturers of e-cigarettes sued and, in 2010, a federal appellate court ruled that they should be regulated like tobacco products under the Family Smoking Prevention and Tobacco Control Act.5,6
The debate about the use of e-cigarettes has escalated since then. Proponents say it represents a “pathway to the reduction or cessation of tobacco use,” whereas “opponents characterize it as a dangerous product that could undermine efforts to denormalize smoking.” Some posit that by filling the vast chasm left by the stigmatization of smoking, e-cigarettes are “renormalizing” smoking.2 And, in the absence of federal regulations, manufacturers of e-cigarettes are furiously advertising, betting that “vaping” may eventually surpass smoking.
Last September, attorneys general from 40 states sent a letter to the FDA asking the agency to meet its stated deadline of October 31, 2013, “to issue proposed regulations that will address the advertising, ingredients, and sale to minors” of e-cigarettes. Although the FDA has submitted a proposed rule (not made public) to the White House Office of Management and Budget and Office of Information and Regulatory Affairs for review,5 it has not yet been determined what will happen and when.
In the meantime, cities and states are imposing their own regulations: New Jersey, Utah, and North Dakota have instituted statewide bans, and in his last bill-signing session before leaving office, New York City Mayor Michael Bloomberg banned the use of e-cigarettes in public, joining 100 other cities that have also instituted indoor smoking bans.5
Do e-Cigarettes Actually Help People Quit Smoking?
An estimated 400,000 tobacco-related deaths occur in the United States annually.2 Public health advocates argue that for people who are disproportionately “at the lower end of the socioeconomic spectrum,” e-cigarettes represent an opportunity to quit smoking. “Although the evidence is limited and contested, some studies suggest that the majority of e-cigarette users treat them as cessation aides and report that they've been key to quitting smoking,” the advocates wrote in The New England Journal of Medicine.5
Studies comparing e-cigarettes with nicotine-replacement therapies found favorable outcomes among those returning to smoking 6 months after attempting to quit—but found no statistically significant difference in the ability of smokers to quit.7,8 Studies also “consistently reveal that most people who use e-cigarettes are so-called ‘dual' users, meaning that they use e-cigarettes as well as paper-and-tar cigarettes.”5
In an article in JAMA's January 8, 2014 theme issue on smoking, Tim McAfee, MD, MPH, director of the Office on Smoking and Health at the Centers for Disease Control and Prevention said that, for adults, the message clinicians should convey to patients is “complicated,” in that “we don't want to discourage people from trying to quit, but we don't want to encourage them to get settled in dual-use land.”5
Also writing in JAMA's theme issue, David B. Abrams, PhD, of The Schroeder Institute for Tobacco Research and Policy Studies at the Legacy Foundation, Johns Hopkins Bloomberg School of Public Health, in Baltimore, MD, noted that “clinicians counseling patients about smoking cessation should first recommend FDA-approved, evidence-based treatments for cessation. However, for smokers who cannot quit, clinicians could point out the reduced harms associated with noncombusted nicotine products.”9
Are They a “Gateway” Product for Adolescents?
In the United States, nearly 90% of adult smokers began smoking by the age of 18.10 For that reason, it may be especially worrisome that, between 2011 and 2012, data from the National Youth Tobacco Surveys showed significant increases in current use of nonconventional tobacco products, such as e-cigarettes and hookahs, among middle school and high school students.3 One in 10—or 1.8 million—students had tried an e-cigarette in 2012, double the 1 in 20 students reported in 2011.11
The attorneys general note that e-cigarette advertising caters to minors by using cartoon monkeys and fashionable “vapor jackets,” and by containing “fruit and candy flavors—such as cherry, chocolate, gummy bear, and bubble gum—that are appealing to youth,” flavors the FDA has banned from cigarettes. In addition, “e-cigarettes and refills of the liquid nicotine solution used with e-cigarettes can easily be ordered online without age verification. By intentional use or mistaken ingestion from the non–child-resistant containers, e-cigarettes and liquid nicotine refills can deliver dangerously high doses of liquid nicotine to youth,” the attorneys general wrote in their letter to the FDA.12