e-cigarettes: what you should know

Over the past few months, I’ve seen articles on e-cigarettes frequently in the popular press and in medical journals – so I thought you might like the scoop on this misnamed device. It sounds like a virtual cigarette you might find on the internet, but it’s not. It’s very real, and although it has one possible benefit, there are many potential problems.

In case you haven’t been stopped by one of the e-cig salespeople in a mall, let’s start with explaining what an e-cigarette is. It’s a battery-powered device which looks like a cigarette. At the top is a disposable cartridge that has a small amount of nicotine-containing fluid. When the power is on, and the user inhales, the heating element warms the cartridge and the air, causing it to aerosolize. A fog that resembles smoke can then be inhaled or ‘vaped’, and exhaled making it appear similar to a cigarette.

I first saw e-cigarettes at a mall a number of years ago. Just like the people who try to convince you that you need some body lotion, face cream, or massage chair, someone stopped me to convince me to try an e-cigarette. I remember him telling me that there’s nothing of concern in it – it’s just nicotine, none of the cancer-causing chemicals that are in real cigarettes. Well, of course he didn’t know I was a lung specialist, and there was no need for me to tell him at that moment.  Although nicotine might not cause cancer, it certainly is addictive. In fact, research shows that it’s as addictive, if not moreso, than cocaine or heroine. The salesman said it could help people to decrease their use of cigarettes. Fair enough, but what about kids and others who weren’t already addicted to nicotine, couldn’t this look ‘cool’ and cause them to get started? 

There are many concerns about the easy availability of these devices. For one thing, they are poorly regulated, so the contents of the cartridges may vary, as may their safety. To put things in perspective, a cigarette contains 1-2 mg of nicotine; the lethal dose for a child is estimated to be 10 mg, and the cartridges typically contain up to 20 mg of nicotine. Refill kits containing up to 1000 mg allow consumers to fill used cartridges with solution at higher doses than the original contents. For that matter, instructions for filling the cartridge with other substances for inhalation can be found on YouTube – I won’t be providing those references here.

The vehicle in which the nicotine is delivered is most often propylene glycol, which has not been studied for inhalation in humans, particularly not over a long period of time. Although the manufacturers claim not to be targeting youth, flavorings such as ‘Atomic Fireball’ argue otherwise. The Center for Disease Control and Prevention (CDC) reported that the number of youth who tried e-cigarettes doubled between 2011 and 2012 – bringing the number to 1.8 million middle and high school students nationwide trying them in 2012. The majority of them also smoked regular cigarettes, but 160,000 in one survey had tried ONLY e-cigarettes – a ‘harmless’ first step to nicotine addiction.

Testing of the devices show that they don’t always contain what they are supposed to, and that they do not efficiently deliver nicotine. Most often, they are used by current smokers as a less expensive nicotine alternative compared with cigarettes. In fact, by keeping consumers in the habit of putting a cigarette in their mouth, not feeling satisfied, then going for more cigarettes, they may perpetuate the habit rather than diminish it. Since they haven’t been shown to decrease smoking, the concern in the medical community is that they might be used as a ‘bridge’ for use where smoking is prohibited, as in office or apartment buildings, or as an intro to smoking, as in the students mentioned above.

Another problem was revealed in an article in the journal Chest in June, 2012. Immediately after inhaling an e-cigarette for 5 minutes, healthy smokers without lung disease had measurable changes in their airways, similar to those seen after a real cigarette. It is not clear what the effect would be in those who already have chronic airways disease, as smokers often do.

The manufacturers argue that stricter regulation of e-cigs or withdrawing them from the market would harm consumers, forcing some of them to go back to smoking. On the contrary, there are many products on the market now, including a prescription (i.e. regulated) cigarette-type device without the energy source or vapor (Nicotrol), chewing gum, patches, lozenges, nasal spray and pills to decrease the craving, that can be used instead. Free help for quitting is available at 1-800-QUITNOW or www.cdc.gov/tips.

Evidently, the FDA intends to become more involved with regulation, but there is no specific timetable. FDA action would be consistent with the government’s goal to “…reduce disease and death from tobacco use.” (CDC) Cigarette smoking remains the leading preventable cause of illness, disability and death in the US since it contributes to so many chronic problems, including heart disease, stroke, peripheral arterial disease and multiple cancers, to name a few. For each death it contributes to, there are 20 people living with smoking-related illnesses. Think about how much that contributes to our national health costs.

Altria, the US division of Marlboro, is responsible for about half of the US cigarette market. In the Wall Street Journal this week, it was reported that Altria will start marketing e-cigarettes, presumably to compensate for falling sales of real cigarettes. Their version, though, uses tobacco instead of liquid as the vehicle. The manufacturers of Camels and Newports are also expected to launch e-cig versions of their own. With all of these varieties, we are in uncharted territory and can’t be sure what the health risks are. Each flavor devised might involve different chemicals that have had some use over the years, but not necessarily involving heating and inhaling them. If you hear that Richard Carmona, former US Surgeon General from 2002 to 2006 has a favorable view of e-cigarettes, just be aware that he has a paid position on the board of NJoy, a producer of electronic cigarettes. Former House speaker, J Dennis Hastert, and other former Congresspeople are lobbying for other companies.

The popularity of e-cigs is likely to continue to grow over the next few years, and regulation of them is likely to be highly politicized. After all the changes in laws over the past few decades regarding regular cigarettes, we are likely to hear similar debates about e-cigarettes – who can buy them, how they are marketed, where they can be sold, how much to tax them and where they can be ‘vaped’. Millions have already been spent on lobbying efforts. We’ll keep you posted!

1) www.cdc.gov/media/releases/2013/p0905-ecigarette-use.html. E-cigarette use more than doubles among US middle and high school students from 2011-2012.
2) Avdalovic, M. and Murin, S. Chest 2012; 141(6):1371-1372. Electronic Cigarettes: No Such Thing as a Free Lunch…or Puff.
3) Cobb, N. and Abrams, D. NEJM 2011; 365:193-195. E-cigarette or Drug-Delivery Device? Regulating Novel Nicotine Products.
4) Wall Street Journal 12/20/2013 Makers of Marlboro Join E-Cigarette Push.
5) Washington Post 9/10/13 E-smoking: It’s safety is still up in the air.
6) Washington Post 10/7/2013 Lobbying to shape e-cigarette debate.