Electronic cigarettes

Secondhand Vaping Poses Hazard to Children

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The harmful effects of exposure to secondhand electronic cigarette vapor can be observed in both the blood and saliva of children whose parents smoke electronic cigarettes.

Despite misconceptions that secondhand exposure to electronic cigarette vapor does not affect bystanders, metabolites indicative of exposure are present in the blood and saliva of children whose parents smoke electronic cigarettes, according to research presented at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 13 to 16, 2024, in Denver, Colorado.

In many cases, parents are not aware of the hazards associated with exposing children to secondhand electronic cigarette vapors. More than half (11 of 19) parents who participated in a focus group stated that they believed using electronic cigarettes with their child nearby was either a minor health hazard or not a health hazard at all, and 12 of 22 parents did not know whether electronic cigarette vapor was harmful to children, reported Jeannie Rodriguez, PhD, RN, CPNP-PC, and coauthors from Emory University Nell Hodgson Woodruff School of Nursing and Rollins School of Public Health.

Blood tests are considered the gold standard for assessing exposure to secondhand smoke; this study was unique in that saliva testing from both passive drool and exhaled breath condensate were also incorporated.

Researchers found that saliva testing is a reliable tool for detecting secondhand smoke exposure in children; when comparing children aged 4 to 12 years whose parents use electronic cigarettes daily to children in the same age group whose parents do not smoke, metabolites that indicate exposure significantly differed between the two groups’ test results.

“This study has implications for parent education regarding the effects of vape smoke,”  said Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP. “Having a less invasive method to document the untoward effects of vape smoke on their children might affect the parents’ intention to stop the habit,” said Mary Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP.”

Multiple detrimental effects are observed when children are exposed to secondhand electronic cigarette vapors; researchers found metabolites linked to dopamine disruption, oxidative stress, and inflammation present in these children that were not found in the control group.

The results of the blood and saliva tests were shared with parents to indicate the hazards associated with exposing children to secondhand electronic cigarette vapors.

Three key themes emerged from focus group interviews with parents: first, some parents turned to electronic cigarettes as a means to quit using traditional cigarettes. Second, some participants had a perceived belief that smoking electronic cigarettes is not as harmful as smoking traditional cigarettes. Finally, participants noted that the power of nicotine addiction compelled them to use electronic cigarettes regardless of their knowledge of potential harm.

“The appeal for vaping is that at least in my mind. and I say this all the time to people that ask me, vaping for me is probably about 95% better than smoking cigarettes,” said one parent.

These themes present barriers to cessation of electronic cigarette use for parents. The research team encourages nurse practitioners and all healthcare professionals to discuss secondhand exposure to both electronic and traditional cigarettes with families. By debunking the misconception that exposure to secondhand electronic cigarette vapor is not harmful to children, clinicians can help reduce their pediatric patients’ exposure to hazardous smoke.

The authors concluded by emphasizing that nurse practitioners and other health care professional much address the harmful effects of vape smoke exposure, as well as  second hand smoke, with their families during health care visits.

Exposure to electronic cigarettes in indoor workplaces

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Electronic cigarettes can negatively affect indoor air quality and pose a risk of secondhand exposure in workplaces. Learn more about what employers can do to eliminate exposures.

Electronic cigarettes are also called “e-cigarettes” or “e-cigs.” Some e-cigarettes look like regular traditional cigarettes but some look like USB flash drives, pens, and other everyday items. When a user breathes in on an e-cigarette, it heats a liquid to form a mixture of very small liquid droplets and gases in the air that are inhaled directly into their lungs. These droplets are approximately one to two micrometers in size (the diameter of a human hair is around 100 micrometers). Both the droplets and gases can contain harmful chemicals.1 When the user breaths out, a portion of this mixture is released into their surroundings, which can negatively impact indoor air quality.

Using e-cigarettes is common in some U.S. workplaces. Employees in indoor workplaces that allow using e-cigarettes are at risk of involuntary secondhand exposure to these harmful chemicals. Further, many non-user employees perceive that using electronic cigarettes at work contributes to reduced productivity.2 Examples of these workplaces include:

  • Homes
  • Vehicles
  • Buildings
    • E-cigarette retailers
    • Bars
    • Nightclubs

Potential harmful effects

The very small size of particles given off by e-cigarettes means that they can deposit in the mouth, nose, and deep in the lungs of user and non-user employees.3 Additionally, NIOSH researchers report concerns for primary users such as:

  • Cavities and gum diseases
  • Upper and lower respiratory tract irritations as well as lung cancer
  • Irritation and toxicity (short- and long- term) to the skin, urinary tract, and liver4

Prevent exposures in the workplace

Employers can:

  • Establish a smoke-free indoor workplace, including free of e-cigarettes, to protect employees from involuntary, secondhand exposures.
  • Promote smoking cessation programs as part of an overall tobacco-free workplace.

Employees can:

  • Where possible, choose employment at a tobacco-free workplace.
  • Encourage co-workers or personally seek resources for e-cigarette (and tobacco smoking) cessation, for example by calling the free smoking quitline at 1-800-QUIT-NOW.

References

  1. LeBouf RF, Burns DA, Ranpara A, Attfield K, Zwack L, Stefaniak AB [2018]. Headspace analysis for screening of volatile organic compound profiles of electronic juice bulk material. Anal Bioanal Chem 410:5951-5960.
  2. Romberg AR, Diaz MC, Briggs J, Stephens DK, Rahman B, Graham AL, et al. [2021]. Vaping in the workplace prevalence and attitudes among employed US adults. J Occup Environ Med 63:2061.
  3. Ranpara A, Stefaniak AB, Fernandez E, LeBouf RF [2021B]. Effect of puffing behavior on particle size distributions and respiratory depositions from pod-style electronic cigarette, or vaping, products. Front Public Health 9:750402.
  4. Stefaniak AB, LeBouf RF, Ranpara A, Leonard SS [2021]. Toxicology of flavoring- and cannabis-containing e-liquids used in electronic delivery systems. Pharmacol Ther 224: 107838.
  5. Wang TW, Marynak KL, Agaku IT, King BA [2017]. Secondhand exposure to electronic cigarette aerosol among US youths. JAMA Pediatr 171:490–92.

Why Vaping is an “Epidemic” and Why It Will Be Tough for the FDA to Stop It

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E-cigarettes, vaping

Vaping has become so prevalent that it’s easy to forget that electronic cigarettes were only introduced in the United States in 2006. Twelve years later, the Food and Drug Administration appears to regret the its relaxed stance on the devices.

This week, FDA Commissioner Scott Gottlieb, M.D., announced that, despite their potential to help adult smokers transition from combustible tobacco products, the current acceleration of e-cigarette use by teenagers is cause for alarm.

Essentially, teens aren’t vaping to quit cigarettes; instead they’ve “invented a new kind of bad habit,” according to a memorable recent assessment in The New Yorker.

Vaping: “An Epidemic”

The commissioner says that use of e-cigarettes by teenagers has now reached “nothing short of an epidemic proportion of growth.” In a briefing with reporters Gottlieb said that in 2017 more than two million middle and high school students were regular users of e-cigarettes.

In his statement, Gottlieb emphasized that calling the teenage use of e-cigarettes an epidemic was nothing something to be taken lightly, explaining:

I use the word epidemic with great care. E-cigs have become an almost ubiquitous — and dangerous — trend among teens. The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable. I’ll be clear. The FDA won’t tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products.

Vaping in California.
Vaping in California.

What’s the Definition of an “Epidemic”?

The CDC and the FDA define an epidemic as “the occurrence of more or more cases of disease than expected in a given area or among a specific group of people over a particular period of time.” An outbreak, meanwhile, would be an epidemic limited to localized increase in the incidence of the disease.

While the word “disease” is used here, the FDA has previously used the phrase ‘epidemic’ to describe situations where a massive amount of people are at risk because of a substance. The opioid epidemic and the tobacco epidemic are two instances in which the phrase was considered appropriate.

When Vaping Became So Popular

And the occurrence of e-cigarette smoking among teens has massively expanded in a short period of time: According to a 2016 Surgeon General report e-cigarette use grew by 900 percent among high school students from 2011 to 2015.

The CDC also states that in 2017 approximately 3.3 percent of middle school students reported they used e-cigarettes in the past 30 days, an increase from just 0.6 percent in 2011. Meanwhile, among high school students in 2016, nearly 12 out of every 100 students did the same — an increase from 1.5 percent of high school students in 2011.

That’s a problem when the use of e-cigarettes is far from healthy. While they are less risky than regular cigarettes, almost all include nicotine, an addictive substance that can negatively affect adolescent brains. Scientists are also concerned that e-cigarette use can contribute to DNA damage associated with oral cancers.

How Does One Stop a Teen From Vaping?

(Good luck.)

How to combat teen access, and interest in, e-cigarettes is something that the FDA is currently attempting to figure out. The fact of the matter is that vaping is seen as cool; schools across the country have reported an increase of teens sneaking e-cigarettes onto campus with some schools even installing sensors to catch them in the act.

Vaping has a huge presence on Instagram; teens show off smoke tricks and Juuls are presented as status symbols.

The FDA says that device makers have 60 days to prove they can keep teens from buying their products and if they fail they’re at risk of being removed from the market entirely. According to the National Institute on Drug Abuse, seven out of ten teens are exposed to e-cig ads.

Juul — the preferred brand of teens — spokeswoman Victoria Davis tells The New York Times that the company is having problems getting Instagram, Facebook, and Amazon to take down ads geared towards youths. Epidemic or not, e-cigarettes still sell.

Are E-Cigs a Gateway to Smoking?

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Lots of questions remain about the effects that using electronic cigarettes have on adolescents, including whether they are a “gateway” drug to regular cigarettes, several speakers said Wednesday.

Most young people who use them also use other forms of tobacco.

“Do e-cigarettes cause children to progress to other tobacco products that are extremely harmful?” Andrea Villanti, PhD, MPH, director for regulatory science and policy at the American Legacy Foundation’s Schroeder Institute for Tobacco Research and Policy Studies here, asked at a briefing on public health challenges related to e-cigarette usesponsored by George Washington University. “To know that … we need to track patterns over time. We need to know if ‘never users’ stayed never users, transferred to combustible use, dual use, or e-cigarette use, and what happened over time.”

Whether e-cigarettes are a gateway to other types of tobacco use is unclear, but surveys do show that the number of young people using e-cigarettes alone is small, Villanti said. “The bulk of e-cigarette use is happening among people using other tobacco products.”

For example, the University of Michigan’s “Monitoring the Future” survey for 2014 found that among 12th graders, 62% had used neither e-cigarettes nor conventional cigarettes, while 4% had used e-cigarettes only, 21% had used conventional cigarettes only, and 13% had used both.

E-cigarettes have gone through several iterations since they were first introduced, explained Naomi Freedner-Maguire, principal researcher at ICF International, a Fairfax, Va., consulting firm. While first-generation products tried to mimic the look of conventional cigarettes, the next generation, also known as “personal vaporizers,” were two-part devices with a tank and a separate battery, and offered thousands of flavor choices to users.

Today, there is a third generation of devices available, with the biggest difference being “mods” — components that can be modified to change the vaping experience, Freedner-Maguire said. “This is a much more effective nicotine delivery system, and it’s moved into a subculture of e-cigarette users and ‘vapers’ that are really committed to creating mods that will increase the power of the device or the flavor.”

“Sub-ohming” — modifying the coils in the atomizer to produce more vapor — is a popular pastime among e-cigarette users, she continued. “There’s a whole vaping culture dedicated to producing as much vapor as possible.”

Some people call themselves “cloud-chasers,” said Freedner-Maguire, “and there are cloud-chasing competitions where people square off back-to-back and inhale, and release the biggest plume of vapor that they can. Somebody stands with a yardstick on the other side and measures the size and density of the plume, and there are cash prizes for things like this.”

“Dripping” is another popular practice, in which “nicotine e-liquid is dripped directly onto wicked material in the atomizer to simulate more closely the experience of smoking a cigarette,” she said. “You can find these things on blogs and all over online about how people inhale, and the difference between mouth inhalation versus lung inhalation — a ‘lung hit.'”

Surveying young people about their e-cigarette use is complicated for many reasons, saidJennifer Pearson, PhD, MPH, a research investigator at the Legacy Foundation’s Schroeder Institute. For one thing, “E-cigarettes have many names. What’s a vape pen to someone in California is an e-hookah to someone in the Northeast, and who knows what to someone in Texas,” she said.

In addition, “young adults might call products different things than older adults,” Pearson continued. “If it’s an older adult, they might call it an e-cigarette and a younger adult might call it an e-hookah.”

Then there’s the issue of dosing. “It’s easy to ask about cigarettes per day, but with e-cigarettes it’s not sensible to ask that — even disposable ones can last several days,” said Pearson. “We’re telling people a ‘use episode’ is when you use an e-cigarette, then put it down and don’t intend to pick it back up for a while.”

 The fact that e-cigarettes are used differently from conventional cigarettes also raises other questions, said Ray Niaura, PhD, associate director for science at the Schroeder Institute.

With conventional cigarettes, “They’re very much compelled to smoke the entire thing,” said Niaura. “That means the way nicotine is delivered into the brain is very different; you’re getting a very intense bolus of inhaled nicotine. With e-products, if you work at it, you can do that, but is that how people really use them?”

Instead, “you can take a puff, put it in your pocket … and walk around, then take another couple of puffs. I don’t know the liability [of that] for producing long-term addiction.”

Do e-cigarettes help people quit smoking conventional cigarettes? “The evidence there is mixed,” he said. “There are a couple of randomized trials, but they’re not slam-dunk positive and not slam-dunk negative.”

Electronic cigarettes: peering through the smokescreen

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Health professionals and their patients have every reason to feel confused. One week the WHO issues a position paper calling for strict regulations on electronic nicotine delivery systems (ENDS), more commonly referred to as electronic cigarettes, including restrictions on marketing and a ban on using them in enclosed public spaces.1 The next week, a group of scientists attracts widespread media attention, with headlines claiming that these products could save 50 000 lives in the UK,2 although this figure appears nowhere in the corresponding paper.3 What is one to make of these conflicting messages?

Before reviewing the evidence, some context is necessary. For several decades the tobacco industry, which has been rapidly increasing its share of the market for ENDS sold in the UK,4has actively sought to create confusion. It did this very successfully when it sought to block bans on smoking in public places, engaging in a massive campaign of deception.5 It sought to portray second-hand smoke as harmless, even though its own research showed that sidestream smoke was even more toxic than directly inhaled smoke.6 It also promoted the idea that a ban would hit the takings of bars and restaurants, even though it had funded the only research to show such an effect.7 As one of its leading scientists claimed, in discussions with lawyers advising on the tobacco industry’s strategy, ‘he could bring a healthy scepticism to … some of the claims being made about environmental tobacco smoke’.6 The industry has also been very good at displacing attention from more important issues, and it is noteworthy that, since the apparent controversy about ENDS has erupted, there has been virtually no media coverage of the UK government’s failure to take forward its commitment on standardised packaging, another area where industry funded research has been used to create a misleading appearance of uncertainty.8 Hence, in an area that is potentially so important to the large tobacco manufacturers, an impression of academic doubt and uncertainty is to be expected.

So where should health professionals look to help their patients reach a decision about ENDS? There is no shortage of advice. The manufacturers of these products have established a massive online presence, many apparently from individual users (self-styled as ‘vapers’) whose enthusiasm for these products is such that they seem to spend many hours each day blogging and tweeting their benefits free from the constraints that would be imposed if they were producing official advertisements. More worryingly, they also engage in grossly offensive online attacks on anyone who has the temerity to suggest that ENDS are anything other than an innovation that can save thousands of lives with no risks,9 with at least one of the most active individuals affiliated to an organisation known to receive tobacco industry funding.10Interestingly, despite attacking critics of ENDS for seeking to prevent use of what they see as life-saving devices, some of these bloggers are equally critical of measures such as standardised packaging, that really would reduce tobacco induced harm. There are also a few health professionals, largely drawn from the field of nicotine addiction (along with some whose background is in harm reduction among intravenous drug users who see an analogy), who do consider that they may help the particular group of patients they work with and who have been especially vocal in eliciting support for ENDS.

In marked contrast, patients and health professionals can seek advice from any of a number of leading national and global health organisations (box 1) that take a quite different view. Each has undertaken detailed reviews of the available evidence, and while noting that there are still many gaps, reflecting the novelty of these products, the lack of data on the long term effects of deeply inhaling the many flavouring additives and by-products of the heating system, such as a range of metals, and natural suspicions about the rapidly growing presence of the tobacco industry in this market. There is a high level of consensus among these organisations, supported by the systematic review undertaken for the WHO.11 Based on their assessments, it is possible to offer some answers to questions that might be asked by those contemplating using ENDS.

Box 1 Sources of authoritative advice on ENDS

Forum of International Respiratory Societies

‘… electronic nicotine delivery devices should be restricted or banned until more information about their safety is available. If they are allowed, they should be closely regulated as medicines or tobacco products.’33

International Union against Tuberculosis and Lung Disease

‘The safety of electronic cigarettes (ECs) or electronic nicotine delivery systems (ENDS) has not been scientifically demonstrated. Adverse health effects for third parties exposed (second-hand exposure) cannot be excluded because the use of electronic cigarettes leads to emission of fine and ultrafine inhalable liquid particles, nicotine and cancer-causing substances into indoor air. The benefits of e-cigarettes have not been scientifically proven. … ENDS could undermine the implementation of the WHO Framework Convention on Tobacco Control.’34

American Heart Association

‘There are concerns that e-cigarette use and acceptance of e-cigarettes has the potential to renormalise smoking behaviour, sustain dual use, and initiate or maintain nicotine addiction. Their use also could serve as a gateway to reinitiation of smoking by ex-smokers. Unregulated e-cigarette use also has the potential to erode gains in smoking cessation and smoke-free laws. The AHA [American Heart Association] considers e-cigarettes that contain nicotine to be tobacco products and therefore supports their regulation under existing laws relating to the use and marketing of tobacco products.’35

UK Faculty of Public Health

‘What we really need is for electronic cigarettes to be subject to the same controls as tobacco, and e-cigarettes to be treated as a tobacco product, so they cannot be marketed or advertised.’36

British Medical Association

‘It is encouraging that the WHO shares our concerns surrounding e-cigarettes and has joined us in calling for stronger regulation.… Tighter controls are needed to ensure their use does not undermine current tobacco control measures and reinforces [sic] the normalcy of smoking behaviour.’37

If I use ENDS, will I reduce my risk of getting smoking-related diseases?

Self-evidently, any health effects of using ENDS will be different from those of smoking as the composition of what is inhaled is different. ENDS do not contain the tar that is the main cause of lung cancer. However, although the advocates of ENDS argue that nicotine is ‘as safe as caffeine’, it is now clear that this is not the case. Its effects may have been obscured by being mixed with tar in cigarettes, but there is growing evidence that it interferes with cellular messaging in ways that are likely to promote cancer development in normal cells12 and promote tumour growth and spread of existing cancers.13 ENDS users achieve similar levels of serum cotinine, a marker of nicotine absorption, as is seen with traditional cigarettes.14 While this is an area where more research is needed, as recognised by the International Agency for Research on Cancer, which has prioritised research on its effects,15 the precautionary principle would suggest that the advice that pregnant women and breastfeeding mothers should stop smoking should also cover ENDS.16

Further concerns relate to the other substances produced by ENDS. Although advocates commonly state that this is only water vapour, this is not the case. ENDS produce levels of ultrafine particles that are similar to those with traditional cigarettes17 and these are associated with release of nitric oxide, suggesting a potential hazard to those at risk of cardiovascular disease.18

There are also concerns about levels of cytotoxic metals in e-cigarette vapour, produced by heating elements,19 certain flavourings, such as diacetyl, known to cause lung serious disease,20 and a range of other chemicals. Advocates of ENDS respond that many of these are present in low levels, but ignore how some users may be inhaling these deep into their lungs for decades and, just because something is considered safe as a food additive, this does not mean that it is safe when inhaled over such a period.

Will ENDS help me to quit smoking?

Although there is a wealth of anecdotes from the advocates of ENDS, the single randomised controlled trial found that ENDS were not significantly better than standard nicotine replacement therapy (NRT).21 This was despite this trial placing barriers in the path of those randomised to NRT, who were required to take a voucher to a pharmacy to obtain it. Given the absence of robust experimental evidence, advocates of ENDS selectively cite observational studies, ignoring those that challenge their arguments. An example is the analogy with smokeless tobacco, or snus, legally sold in Sweden, with frequent use of a graph showing a decline in smoking coinciding with increased use of snus. Yet, disaggregation by sex shows similar changes in smoking by men and women although snus use is extremely rare among women.22Another widely cited example uses observational data from England, arguing that the chances of success among those intending to quit are twice as high among those using e-cigarettes compared to those using NRT. Yet, these data show that 80% of those attempting to quit with ENDS in the preceding year were still smoking, hardly a miracle solution, and inexplicably the success rate among those using NRT was lower than among those whose attempts were unassisted.23 There is also a risk that the use of ENDS may reduce the intention to quit completely. In summary, therefore, this is an area where robust evidence of effectiveness is missing.

Will I improve my health chances if I use ENDS to help me cut down on cigarettes?

The risks associated with smoking are non-linear, which is unsurprising given the many toxic substances in tobacco smoke and the diverse organs that they act upon. However, there is now good evidence from a number of cohort studies showing that those cutting their cigarette consumption by more than half obtain few health benefits.24–26 The only benefit is a reduction in lung cancer, but even that was smaller than expected. Hence, the evidence is clear. To achieve health benefits it is necessary to quit, not cut down.

Should I take any precautions with ENDS and their contents?

Nicotine is a potent poison.27 Yet the introduction of ENDS means that concentrated solutions are now being packaged in colourful containers and mixed with flavours that seem designed to appeal to children, such as ‘Gummy Bears’ and bubble gum. In these circumstances, it is unsurprising that there are increasing instances of poisoning of those ingesting the contents of containers.28 Hence, it is important that ENDS be stored safely, where children and pets are unable to access them.

Discussion

These questions are likely to be the ones most commonly asked of health professionals. However, in their role as advocates for health, it is important that they also take account of the wider context. ENDS manufacturers, now dominated by the major tobacco companies, engage in intensive marketing that seems to be targeted at young people. Thus, a group of US senators has described their sponsorship of sports events and use of flavours and images of celebrities that appeal to young people,29 with their concerns borne out by studies from the USA30 and UK.31 A further concern is the manufacture of what are termed electronic shishas, which contain flavours but no nicotine and so, in many countries, can be sold to children, thereby getting them into the habit of using the same equipment as with ENDS. This marketing also seems to be designed to circumvent advertising bans, for example by the promotion of products looking like cigarettes and packaged in ways that look like established brands. There are also concerns that the use of products that resemble cigarettes (so-called cigalikes) will renormalise the imagery of smoking that has been so effective in movies, where cumulative exposure to scenes of smoking are strongly correlated with youth smoking.32 Finally, it is clear that the tobacco industry, by presenting itself as part of the solution to smoking related illness, is using ENDS to return to the days before the Framework Convention on Tobacco Control when it still had open access to governments.

From a public health perspective, any innovation should prompt three questions. Is it safe, does it work, and who benefits from its introduction? There are still very large gaps in the evidence but, on the basis of what is known, the answers are that ENDS may be safer than traditional cigarettes but there are many reasons for concern about their safety, especially if they are to be used over many years. They may help some people to quit, but do not seem to be any better than NRT and neither are particularly effective. And the beneficiaries are clearly the tobacco companies, who have shown once again their ability to sow confusion in the eyes of the public and now see a prospect of reinventing themselves as legitimate businesses with whom politicians are no longer ashamed to be seen in public.

Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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‘Ban E-cigarette use indoors,’ says WHO.

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Smoking an e-cigarette

There are more than 8,000 different flavours of e-cigarettes

The World Health Organization says there should a ban on the use of e-cigarettes indoors and that sales to children should stop.

In a report the health body says there must be no more claims that the devices can help smokers quit – until there is firm evidence to support this.

WHO experts warn the products might pose a threat to adolescents and the foetuses of pregnant women.

But campaigners say regulations must be proportionate.

Tempting flavours

According to the WHO legal steps need to be taken to end the use of e-cigarettes indoors – both in public spaces and in work places.

And the report focuses on the potential for products to spark wider cigarette use in children.

The health experts call for a ban on advertisements that could encourage children and non-smokers to use the devices.

And they say fruit, candy or alcoholic-drink style flavours should be prohibited too, while the sales of electronic cigarettes from vending machines should be heavily restricted.

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Graphic: What's inside an e-cigarette?

1. On some e-cigarettes, inhalation activates the battery-poweredatomiser. Other types are manually switched on

2. A heating coil inside the atomiser heats liquid nicotine contained in a cartridge

3. Liquid nicotine becomes vapour and is inhaled. The ‘smoke’ produced is largely water vapour. Many e-cigarettes have an LED light as a cosmetic feature to simulate traditional cigarette glow.

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‘Health threats’

The WHO warns exhaled e-cigarette vapour could increase the background air levels of some toxicants and nicotine.

Observing a lab test comparing traditional smoking with e-cigarettes

According to the team while e-cigarettes are likely to be less harmful than traditional cigarettes, they may pose threats to adolescents and the foetuses of pregnant women who use these devices.

But some researchers suggest tough regulations may prevent smokers having access to products that are potentially less harmful than conventional cigarettes.

A spokesman for the British American Tobacco company said: “We have always said that given nicotine is addictive, minimum age laws of 18 for the sale of e-cigarettes should be introduced.

“However, if overly restrictive regulations are introduced hampering innovation or adult usage, then this could simply stifle the growth of new products and prevent smokers from being aware of and having access to them – this can only be bad thing for public health.”

Charles Hamshaw-Thomas, E-Lites: Ban on indoor use would be “troubling”

‘Proportionate regulation’

Hazel Cheeseman, at the charity Action on Smoking and Health, said there was no evidence of any harm to bystanders and warned regulation needed to be proportionate.

She added: “Smoking kills 100,000 people in the UK alone.

“Smokers who switch to using electronic cigarettes in whole or in part are likely to substantially reduce their health risks.

“Although we cannot be sure that electronic cigarettes are completely safe, as the WHO acknowledges, they are considerably less harmful than smoking tobacco and research suggests that they are already helping smokers to quit.”

Global guidelines

A UK Department of Health spokeswoman said: “More and more people are using e-cigarettes and we want to make sure they are properly regulated so we can be sure of their safety.

“We have already set out our intention to change the law to ban the sale of e-cigarettes to children under 18.

“The UK has an existing licensing system for higher strength products and those that claim to help people quit.

“We are also bringing in new European rules to cover lower strength products which will ban most advertising, limit nicotine levels and set standards for ingredients, labelling and packaging.”

The WHO’s recommendations were published ahead of a meeting involving all countries that have signed up to an international convention on tobacco control.

New global guidelines could be agreed during the October meeting.

E-Cigs: No Help in Quitting, Smoking Less.

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Electronic cigarettes didn’t help smokers quit or even smoke less, according to a longitudinal study that may quash some public health hopes for the nicotine-delivery devices.

Smokers who also reported any e-cigarette use at baseline in the web-based study weren’t significantly more likely to have quit tobacco 1 year later (odds ratio 0.71, P=0.35), said Pamela Ling, MD, MPH, of the University of California San Francisco.

The same was true for prior 30-day e-cigarette use after accounting for baseline intent to quit, cigarette consumption, and dependence (OR 0.76, P=0.46), the group reported in a research letter online in JAMA Internal Medicine.

Among people who didn’t quit, “vaping” wasn’t associated with smoking fewer cigarettes over time either (P=0.25).

These findings from analysis of 949 smokers in a nationally representative panel followed from 2011 through 2012 by web-based market research firm Knowledge Networks (now GfK) add to similar findings from population-based and Quitline studies.

“Although electronic cigarettes are aggressively promoted as smoking cessation aids, studies of their effectiveness for cessation have been unconvincing,” Ling’s group wrote.

For example, one placebo-controlled but underpowered trial suggested e-cigarettes were at least as good as nicotine patches in helping smokers quit, but quit rates were dismal either way at 6% to 7%.

“Regulations should prohibit advertising claiming or suggesting that e-cigarettes are effective smoking cessation devices until claims are supported by scientific evidence,” Ling’s group argued.

The top reason for regular e-cigarette use cited in surveys has been kicking the tobacco habit, and some public health experts have been cautiously supporting that harm-reduction strategy.

“As a harm reduction proponent, I would be willing to put aside the fact that any product with the name ‘cigarette’ (e- or otherwise) causes me reflex tachycardia and support electronic cigarettes … if there were good data indicating that they helped smokers to stop,” JAMA Internal Medicine editor Mitchell Katz, MD, wrote in a note accompanying Ling’s letter.

However, he agreed with their conclusion and further advocated FDA regulation as drug-delivery devices.

While the U.S. Supreme court struck down FDA attempts to regulate e-cigarettes as drugs or devices in 2010, the agency has regulations in the works that are expected to generally bring the same kind of restrictions to e-cigarettes as to other tobacco products.

“The bottom line is e-cigarettes are not a good way to quit,” commented Brian Tiep, MD, director of smoking cessation at City of Hope in Duarte, Calif.

The devices may not have all the carcinogenic compounds found in burning tobacco, but that doesn’t mean they’re entirely safe, he told MedPage Today, pointing to FDA analyses finding carcinogenic nitrosamines and the antifreeze component diethylene glycol in e-cigarette nicotine solutions.

However, he noted that Ling’s study population wasn’t actively trying to quit and that an adequately-powered study is still needed to assess e-cigarettes’ performance in a smoking cessation program.

Ling’s group also cautioned about limited statistical power, as smoking cessation was self-reported and included only nine of the 88 e-cigarette users.

Their study lacked data on how frequently the population used e-cigarettes and motivation for use as well.

The data came from a study funded by the National Cancer Institute.

 

Action Points

  • Electronic cigarettes didn’t help smokers quit or even smoke less, according to a longitudinal study that may quash some public health hopes for the nicotine-delivery devices.
  • Note that while the U.S. Supreme court struck down FDA attempts to regulate e-cigarettes as drugs or devices in 2010, the agency has pending regulations that are expected to generally bring the same kind of restrictions to e-cigarettes as to other tobacco products.

Electronic cigarettes can be dangerous, even if you don’t smoke them

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The Centers for Disease Control and Prevention has identified a new health problem related to electronic cigarettes — the risk that the devices themselves or the liquid nicotine that goes into them will cause injury to eyes, skin or other body parts.

Calls to poison control centers to report problems related to e-cigarette exposures rose from one per month in September 2010 (when officials started to keep track of such calls) to 215 per month in February 2014, according to a report published Thursday in the CDC’s Morbidity and Mortality Weekly Report. During that time, poison control centers fielded a total of 2,405 calls about e-cigarette injuries.

To put those numbers into some perspective, the report also notes that during the same period, Americans made 16,248 calls to poison control centers regarding exposures to regular cigarettes. The monthly number of cigarette-related calls varied between 301 and 512.

Electronic cigarettes are battery-operated devices that deliver users a hit of nicotine in vapor form without the carbon monoxide or tars that come from burning tobacco leaves. The CDC estimates that 10% of American high school students and nearly 3% of middle school students used e-cigarettes in 2012.

The authors of the Morbidity and Mortality Weekly Report — from the CDC and the Food and Drug Administration — found records of 9,839 calls involving either regular or electronic cigarettes that included information on the side effects suffered by victims. Among these cases, 58% of calls involving e-cigarettes reported some kind of “adverse health effect.” In 68.9% of these cases, people became injured by ingesting something, 16.8% by inhaling something, 8.5% by getting something in their eye and 5.9% by getting something on their skin.

When people were injured by e-cigarettes, the most common side effects reported to poison control centers were nausea, vomiting and eye irritation. One person committed suicide by injecting the nicotine solution into his or her veins.

By comparison, only 36% of calls to poison control centers about regular cigarettes reported an adverse health effect — and in 97.8% of those cases, the problems were related to ingestion.

Young children were the ones most likely to be harmed by regular cigarettes, with 95% of victims under the age of 6. By comparison, 51% of those harmed by e-cigarettes were in that age group, and 42% of victims were over the age of 20.

“This report raises another red flag about e-cigarettes — the liquid nicotine used in e-cigarettes can be hazardous,” Dr. Tom Frieden, the CDC director and a vocal critic of e-cigarettes, said in a statement.  “Use of these products is skyrocketing and these poisonings will continue.”

The Morbidity and Mortality Weekly Report noted that the nicotine liquid used in e-cigarettes comes in flavors such as fruit, mint and chocolate. That could make them especially appealing to children, but Frieden warned that the liquid cartridges are not required to be sold in childproof containers.

Most recent data from UK points to substantial public health benefits of electronic cigarettes.

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While most anti-smoking organizations continue to oppose electronic cigarettes (e-cigarretes), warning of the hypothetical risks of these products, new data from the UK suggest that in real life, e-cigarettes are producing substantial public health benefits.

Recent data (monthly tracking of key performance indicators; e-cigarettes in England – latest trends) from the Smoking Toolkit Study (Cancer Research UK, UK Centre for Tobacco Control Studies) reveal the following critical points:

The use of e-cigarettes has increased dramatically, ever since the fourth quarter of 2011.
Precisely coincident with the rise in e-cigarette use in the UK has been a significant increase in quit smoking attempts.
E-cigarettes have surpassed nicotine replacement therapy (NRT) and other drugs as the most commonly used smoking cessation method.
Overall motivation to quit has increased since the dramatic rise in e-cigarette use.
The majority of dual users (e-cigarettes and cigarettes) are using e-cigarettes every day, and half are using at least two cartridges/disposables per day.
Very few non-smokers or long-term ex-smokers are using e-cigarettes.
Report STS140122 (Electronic cigarettes in England – latest trends) draws the following conclusions:

The increase in e-cigarette use prevalence may have stalled;
There is no evidence that e-cigarettes are undermining motivation to quit or reduction in smoking prevalence; and
Use of e-cigarettes by never smokers or long-term ex-smokers is extremely rare.
The rest of the story
Based on these most recent data from the UK, it appears that there just is not evidence to support the wild contentions that anti-smoking groups, advocates, and health agencies like the Centers for Disease Control (CDC) and WHO are disseminating to the public. Contrary to what Stan Glantz [Professor, Department of Medicine, and Director, Center for Tobacco Control Research and Education, University of California San Francisco, US] is telling the press, there simply is no evidence that the use of e-cigarettes is undermining smoking cessation or impeding the decline in smoking prevalence. Nor is there evidence that e-cigarettes are causing non-smokers or ex-smokers to return to cigarette smoking. Moreover, there is no evidence that dual use is decreasing the motivation of smokers to quit or precluding these smokers from reaping any health benefits.

In contrast, however, to the lack of evidence that e-cigarettes are having any negative public health effects, there is strong evidence to suggest that these products are having a substantial positive public health impact. In particular, there is evidence that not only do these products help many smokers quit smoking, but more generally, they increase population interest in smoking cessation, enhance levels of motivation to quit smoking, and lead to increased quit attempts among current smokers.

The only bad news coming out of the actual data is that the efforts of anti-smoking groups and advocates appear to be working: they are being successful in discouraging smokers from trying to quit smoking using e-cigarettes. Ironically, the results of public health efforts have been to impede smoking cessation, lower the overall motivation of smokers to quit, and decreasing the number of quit attempts among current smokers.

In other words, the anti-smoking movement is violating the first principle of public health practice by doing public health harm.

While it is difficult for me to have to criticize anti-smoking groups because these are groups with which I have had a career-long collegial relationship, it appears that these groups are substantially harming the health of the public by impeding smoking cessation. Sadly, this means that their efforts are going to result in a significant amount of unnecessary disease and death.

This is not the way public health is supposed to be. But this is what happens when an abstinence-only mentality takes over in any area of public health, whether it be nicotine addiction or heroin addiction.

 

Are Electronic Cigarettes Safer to Use than Conventional Cigarettes?

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Many smokers around the world are choosing electronic cigarettes (also known as e-cigarettes) in the belief that they are less damaging to their health. Millions of Americans have joined the trend since the tobacco-free devices were introduced domestically in 2007, with sales estimated to reach $1 billion this year.

Pictured: Electronic Cigarette

Although they differ in shape and size, e-cigarettes basically all function in the same way. The user inhales through a mouthpiece, triggering a sensor that turns on a battery-powered heater. This action vaporizes liquid nicotine and activates a light at the tip.

The heater also vaporizes substances such as propylene glycol and glycerol to produce theatrical smoke similar to the white puff produced when exhaling tobacco cigarettes. Flavorings such as mint, chocolate, and bubblegum are often added.

Among the new users are many young people. The number that have tried e-cigarettes doubled from 2011 to 2012, according to the Centers for Disease Control, which estimates that a total of 1.78 million middle and high school children have experimented with the devices.

As the assistant director of Memorial Sloan-Kettering’s Tobacco Cessation Program, Jack E. Burkhalter hears questions and concerns about the safety of e-cigarettes every day.

We asked him to help us sort through the mixed safety messages.

Many Unknowns

Dr. Burkhalter says he often hears smokers claim e-cigarettes must be healthier than conventional cigarettes because they do not contain tobacco. But e-cigarettes do contain a liquid form of nicotine, a highly addictive tobacco component that may cause changes in the developing brains of young people. And the consequences of long-term nicotine use in adults have not even been fully studied, Dr. Burkhalter explains.

“Another problem is that we have no way of knowing what’s in a given product,” Dr. Burkhalter says, as manufacturers and types of e-cigarettes vary widely. “There is no one product — so it is impossible to determine whether any given e-cigarette is in fact safer than a conventional one, or safer than another brand of e-cigarette.”

Most electronic cigarettes sold in the United States are imported from China, which does not regulate or standardize the products. Domestic e-cigarettes are not government regulated, either. As a result, users are left in the dark regarding how much nicotine or other substances they are inhaling.  

What those other substances might be is yet to be determined. While more research on the topic is needed, some studies indicate that e-cigarettes may contain a variety of chemicals, from suspected carcinogens to heavy metals and airway irritants.

Nor has much research been done to determine the health impact of inhaling e-cigarette vapors into the lungs.

“So while they may seem to be safer compared to tobacco cigarettes because they don’t contain tobacco and tobacco smoke, we can’t really quantify if that is the case,” Dr. Burkhalter says. “Overall, I hope for the best—but fear the worst.”

Questions of Safety to Others, and to Youth

I hope for the best but fear the worst. The issue of whether e-cigarettes are safe and actually help smokers quit is a problem we will have to grapple with until we have more evidence.

-Jack Burkhalter, Assistant Director, Tobacco Cessation Program

The health risks of secondhand exposure to tobacco smoke are well established. Still unclear, however, is the impact of secondhand vapor from e-cigarettes, Dr. Burkhalter says. “E-cigarette users may feel more at ease in smoking around others, including children — a decision based on their perception of reduced harm. Unfortunately, this perception isn’t supported with sound scientific data.”   

He also finds the rising numbers of young people trying electronic cigarettes very concerning because the devices might serve as gateway products to tobacco use. According to the CDC report, of the nearly 1.8 million middle and high school children who have tried e-cigarettes, an estimated 160,000 of them have never used conventional cigarettes.

Any exposure to nicotine can have harmful effects on the development of the body and brain in a young person, Dr. Burkhalter notes.

Regulators and Options for People Trying to Quit

“E-cigarettes have an allure, and it’s difficult at times to convince people that instead of turning to products that we still don’t know a lot about, we have evidence-based ones that, unlike the e-cigarette, have been approved by the Food and Drug Administration and have proven track records for enabling many people to break their addition to nicotine,” Dr. Burkhalter explains. 

In addition to nicotine replacement products such as chewing gum, lozenges, and skin patches designed to ease cravings, there is the nicotine inhalation system (such as the Nicotrol® Inhaler) — which he says is the closest in look and feel to the e-cigarette.

But what this prescription-only product doesn’t have is the benefit of styling in appealing shapes and colors, or the illusion, complete with visible vapor puffs, of smoking a cigarette. “Many of my patients won’t be seen with the Nicotrol Inhaler; marketing of the Food and Drug Administration–approved cessation products has not been as sophisticated and aggressive as those for e-cigarettes,” Dr. Burkhalter says.

What these FDA-approved nicotine replacement products do provide is definitive information about their ingredients, including how much nicotine they deliver. They represent tools to use along what is known as the “harm-reduction continuum,” with total abstinence on one end of the spectrum, the use of conventional tobacco cigarettes on the other, and products that offer less damaging alternatives at various points along the middle.

“If the FDA decides that it will start regulating the e-cigarette industry – a ruling on this is expected in the fall of 2013 – we will soon learn a lot more about what is contained in these devices and where they might fit along this harm-reduction continuum,” Dr. Burkhalter explains. Many countries with tobacco control policies are struggling to shape policies regarding safety and the appropriate use of e-cigarettes.

Meanwhile, research about e-cigarette use is under way at Memorial Sloan-Kettering and elsewhere to take stock of how cancer patients use e-cigarettes, whether users are more likely to quit smoking tobacco cigarettes, what sorts of substances the products contain, and what the health risks of inhaling vaporized chemicals might be.

Source: MSKCC