E-cigarettes (e-cigs, for short) are electronic devices that deliver nicotine, and sometimes flavor, through inhaled vapor. Promoters and manufacturers say the products contain far fewer cancer-causing and other toxic substances than traditional cigarettes, and there’s no passive smoke for others to inhale. Plus, e-cigs and might help people quit smoking, marketers suggest.
So, obviously, the increasing popularity of electronic versions of cigarettes has to be a good thing, right? Not necessarily.
A closer look shows the “facts” about e-cigarettes are anything but clear. Debate is in full swing over whether e-cigarettes can reduce both the number of smokers and the related health risks of traditional cigarettes. There are also questions about whether e-cigarettes hold unforeseen perils, especially for teenagers.
Last fall, the World Health Organization (WHO) published a report calling for greater regulation of e-cigarettes, citing them as a potential health threat. WHO claims there’s currently insufficient evidence to conclude that e-cigarettes help users quit smoking and, while e-cigs are less toxic than traditional cigarettes, they still pose threats, particularly to young people and pregnant women.
Almost immediately, a team of addiction experts who support e-cigs as an alternative to cigarettes fired back with a critique of the WHO report in the journal Addiction. "We were surprised by the negativity of the commissioned review, and found it misleading and not an accurate reflection of available evidence. E-cigarettes are new and we certainly don't yet have all the answers as to their long-term health impact, but what we do know is that they are much safer than cigarettes, which kill over 6 million people a year worldwide,” said Ann McNeill, of the National Addiction Center at King's College London.
Although the majority of e-cigarette users perceive the product as a tool to quit smoking, their effectiveness for smoking cessation is unknown. Studies show mixed results. E-cigarettes are not approved as a smoking cessation aid by the Food and Drug Administration. Some small observational studies indicate e-cigs may help smokers cut back on nicotine usage; other studies show no effect. Penn State University researchers surveyed over 3,500 current users of e-cigs who were former cigarette smokers. The results, published in the journal Nicotine & Tobacco Research, showed that, initially, users felt less dependent on e-cigarettes than they had been on traditional cigarettes. However, with continued use, they reported increasing dependence on e-cigarettes over time.
"We don't have long-term health data of e-cig use yet, but any common sense analysis says that e-cigs are much less toxic. And our paper shows that they appear to be much less addictive, as well. So in both measures they seem to have advantages when you're concerned about health,” said lead researcher Jonathan Foulds, PhD, professor of public health sciences and psychiatry at Penn State.
Patches and chewing gum containing nicotine are widely used to help smokers kick their cigarette habit — so it makes sense that e-cigs should also help reduce nicotine cravings. A study published in the International Journal of Environmental Research and Public Health, by Belgian scientists from KU Leuven, concluded that e-cigarettes successfully reduced cravings for tobacco cigarettes and helped with nicotine withdrawal symptoms.
A recent analysis of two controlled studies (e-cigarettes containing nicotine versus placebo e-cigs with no nicotine) along with 11 observational studies published in the Cochrane Review found that people using e-cigs were more likely to decrease their tobacco use. Only one of the studies looked at the effects of electronic cigarettes compared with nicotine patches, but they both seemed to help people quit at about the same rate.
E-cigarettes may help people smoke less, or quit entirely, but healthcare providers are concerned the variety of enticing flavors increase the appeal of e-cigarettes to young people. And several recent studies show electronic cigarettes could be producing more nicotine addicts by attracting non-smokers. A research team from the University of Mississippi and the American Academy of Pediatrics used data from national surveys conducted between 2010 and 2013 to examine adult use of e-cigarettes. Their study, published in the journal Nicotine & Tobacco Research, revealed that although the majority of e-cigarette users were also current cigarette smokers, more than 32 percent of e-cig users had never smoked before or were former smokers.
That shows, the researchers concluded, that e-cigarettes contribute to primary nicotine addiction — and they are calling for federal, state, and local regulation of the products.
More evidence that e-cigarettes could be contributing to a new generation of nicotine addicts: A study by the Centers for Disease Control and Prevention (CDC), published in Nicotine & Tobacco Research, found more than a quarter of a million young non-smokers started using electronic cigarettes in 2013. What’s more, the youth who used e-cigarettes were almost twice as likely to say they planned to smoke conventional cigarettes during the next year as those who had never used e-cigarettes.
While electronic cigarette proponents point to the fact there are fewer toxins in e-cigs than the traditional variety, the CDC counters that nicotine alone is highly addictive and can have adverse and possibly permanent effects on adolescent brains.
"The increasing number of young people who use e-cigarettes should be a concern for parents and the public health community, especially since youth e-cigarette users were nearly twice as likely to have intentions to smoke conventional cigarettes," said Rebecca Bunnell, associate director for science in the CDC's Office on Smoking and Health.
At the annual meeting of the American Association for the Advancement of Science (AAAS), held in San Jose in mid-February, a panel of international scientists and policy makers met to try to sort out the e-cig facts. Pointing out that e-cigarettes are already used by tens of millions of people around the world and sales of the devices are predicted to outstrip traditional cigarettes by 2021, the AAAS participants debated the pros and cons but did agree on one thing.
"Electronic nicotine delivery systems have both promise and concern. Let's remember that cigarette smoking causes one in five deaths in the U.S. every year. Every approach to reducing cigarette smoking should be considered, and e-cigarette use by smokers attempting to quit is promising. Nevertheless, advances in brain and gene research are showing that adolescent exposure needs closer attention. Nicotine is addictive and addiction is a developmental disorder with an abuse trajectory that predominantly starts in one's youth. And addiction has its dark sides,” said William Compton, Deputy Director of the US National Institute on Drug Abuse (NIDA), who advocated taking a middle ground.
“My plea is for an appropriate, rational, scientific appraisal of likely risks and benefits. Above all, we must do more to dispel any youth perception that e-cigarettes cause no harm — they do — while encouraging adults to do everything they can to stop using tobacco products."
March 20, 2015
Christopher Nystuen, MD, MBA