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Electronic cigarette Update - More Potential for Addiction and Poisonings

written by Marsha Seidelman, M.D.
on Sunday, 5th October ,2014

Since December, 2013, when I wrote an overview of electronic cigarettes, they have evidently gained in popularity in the 18-34 age group. This has become a public health issue for many reasons.

1) 88% of people in this age group who have used cocaine, had previously smoked cigarettes. There is evidence now that the use of nicotine (which is present in e-cigs and traditional ones) may predispose people to try other addictive substances. A fascinating review in a recent New England Journal of Medicine article showed that when mice were exposed to nicotine for a week, there were chemical changes in the brain, specifically in the reward center that is mediated by dopamine and the area where emotion is orchestrated.  These areas are both linked to addiction. The changes in the brain due to nicotine gave these mice an enhanced effect from cocaine and made it more likely they would become addicted, rather than try it once and walk away. In rats, this predilection for cocaine abuse was even greater in adolescents than in adults. In humans, teens who used e-cigarettes were more likely to try real cigarettes than their peers who didn't try e-cigs.

The concern about e-cigarette use based on these studies and what we've already seen in teens, is that the nicotine involved may be a gateway drug, i.e. predispose the user to use standard cigarettes, cocaine and other substances, .

2) Poison control centers have reported an exponential increase in accidental exposures or overdoses of e-cigs/ liquid nicotine over the past 4 years (see aapcc.org). To be fair, there wasn't a code to denote liquid nicotine exposure specifically until 2010, but the incidence of problems is growing quickly. Over 50% of these exposures involve toddlers under 5 years old. These are mostly oral ingestions, although some are inhalation or skin exposures. In addition to the risk for children and pets, there is danger for adult users as well because of the highly concentrated liquid that is used to refill the cartridges in e-cigarettes. From random testing, it seems that the concentration noted on the label is often inaccurate. Potential side effects include rapid heart rate, vomiting, unsteadiness, seizures, and in the most severe cases, coma and death.

3) After many years of fighting for regulation of traditional cigarettes regarding where they can be advertised, where they can be sold and to whom, what information needs to be on the label, etc., we have no rules in place regarding liquid nicotine for e-cigarette refills. On these refills, there are no health safety warnings or childproof caps. Instead, the labels may have cartoons, have concentrations written in by hand, and advertise flavors such as chocolate, mint or fruit flavors. We've worked so hard for decades to limit teen use of cigarettes. Why create a mirror image with another potentially harmful related product?

4) Manufacturers say that these devices are safe because they do not contain all the carcinogens that are in standard cigarettes. However, the ingredients, including the main one (propylene glycol) have not been tested in the lungs after being heated and inhaled. In fact, a prior article in Chest, the journal of the American College of Chest Physicians (ACCP), showed that irritation in the lung after e-cigarette inhalation or vaping, is similar to changes after inhaling standard cigarettes. We do not know if there is a risk associated with second-hand smoke exposure as there is with standard cigarettes.

5) The ACCP and the American Thoracic Society and other international pulmonary groups released a position statement in July, 2014 stating that risks have not been assessed. There is potential benefit to an individual smoker in that e-cigs might help him/her to decrease traditional cigarette use. But this should be weighed against harm to the population of use of nicotine, appearance of social acceptability of smoking, and potential of prolonging cigarette use by supporting the nicotine addiction.

So overall, there are risks associated with e-cigarettes, in terms of addictions to nicotine as well as being a gateway to other drugs, irritation of the airways and potential poisonings. Therefore, e-cigarettes should be restricted until there is more proof of safety available. They should be regulated as a medication, subject to the same rigorous review as new medications are, or as a tobacco product, with all the rules that have been developed about how they are packaged, where and to whom they can be sold and advertised, where they can be vaped, etc. We can't expect that the industry will hold public health concerns above financial profit.

See the link on WTOP following my interview by Paula Wolfson.


Kandel and Kandel, NEJM, A Molecular Basis for Nicotine as a Gateway Drug, NEJM 2014; 371:932-943

Avdalovic, M. and Murin, S. Electronic Cigarettes: No Such Thing as a Free Lunch…or Puff. Chest 2012; 141(6):1371-1372.

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