The great e-cig debate

(Fred Hutchinson Cancer Research Center) March 6, 2014 - Since electronic cigarettes were introduced to the world a decade ago, they have grabbed headlines, frustrated physicians and thoroughly confused consumers.

“Our patients are highly motivated to quit, but they’re confused about the mixed messages of e-cigarettes,” said Donna Manders, a certified tobacco treatment specialist at Seattle Cancer Care Alliance. “A lot of them believe the hype that is out there, that these must be safe because they’re being sold everywhere.”

Unfortunately, there are far more advertisements, celebrity spokesmodels and new brands of e-cigs than strong, evidence-based studies.

“There’s a lot of excitement but very little data,” said Jonathan Bricker, psychologist and smoking cessation researcher in the Public Health Sciences division of Fred Hutchinson Cancer Research Center. “The FDA has to regulate the device before a researcher can conduct a trial on its efficacy for smoking cessation and the devices aren’t regulated yet. We’re in a Catch-22.”

A bit of vital – and disturbing -- data did trickle in Thursday, with the release of a survey-based study in JAMA Pediatrics that found e-cigarette use by adolescents was associated with higher odds of smoking traditional cigarettes. Researchers from the Center for Tobacco Research and Education at University of California, San Francisco, examined data from 17,000 middle schoolers and high schoolers who were surveyed in 2011 and 22,000 surveyed in 2012.

It’s an ironic development, considering many e-cigarettes -- also known as vape pens or e-hookahs -- are promoted as a smoking cessation tool. Bricker said smoking cessation studies are going on in Europe, Australia and New Zealand, but results won’t be available for at least three more years. Until then, governments around the globe are struggling to balance a dearth of scientific data with increasing safety concerns and skyrocketing consumer demand.

In Australia, Canada and other countries, it’s illegal to sell e-cigs that contain nicotine. And last week, the European Parliament passed regulations to limit the amount of nicotine that can go into the products. (The new regulations also require safety warnings, childproof packaging and ban the advertisement of the product in 28 nations).

Here in the US, New York has banned public e-cigarette use as have New Jersey, Utah and North Dakota. Los Angeles just passed a similar measure Tuesday and Chicago may soon follow suit. But the Food & Drug Administration is still, as Time.com recently put it, “dragging its feet” on regulating the $2 billion industry.

Puzzled by the conflicting information surrounding the e-cig/vape pen issue? Below, a few answers to the many questions patients and the public have about the murky unregulated world of electronic smoking.

Are e-cigs safer than cigarettes?

According to Bricker, a fair amount of data shows that e-cigarettes don’t contain compounds like formaldehyde, benzene and ammonia which tobacco makers add to regular cigarettes to “spike” the nicotine so it acts faster on the brain and boosts the smoker’s addiction.

E-cigarettes are also smokeless. They may look like real cigarettes (some even have an LED on the end that glows red or blue), but there’s no tobacco, no flame, no smoke and no resulting tar and carbon monoxide transferred to an e-smoker’s lungs. Instead, a battery converts liquid nicotine and/or flavors into a fog machine-type vapor known as propylene glycol.

“What we know so far is they don’t have many of those very dangerous ingredients that are added to regular cigarettes,” said Bricker.

Do they help you quit?

Both Bricker and Manders stress that the jury’s still out when it comes to their efficacy as a smoking cessation tool. Although one study published in Lancet in 2013 found the e-cigs were “modestly effective” at helping smokers quit, comparable to nicotine patches.

The study authors added, though, that more research is “urgently needed to clearly establish their overall benefits and harms at both individual and population levels.”

Who monitors the safety and quality of e-cigs coming into the U.S.?

Experts also have questions about the chemicals used in these unregulated products, many of which are produced in China, a country with a history of producing toxic toothpaste, toys with choking hazards and contaminated pet food.

“When things aren’t regulated by the FDA, it means they’re not held up to the same standards of quality,” said Manders. “Harmful products could be placed in the devices and no one will know. The dosage of nicotine could be very high or very low.”

Indeed, Bricker said information presented at the recent Society for Research on Nicotine and Tobacco conference in Seattle indicated that the level of nicotine in e-cigarettes and vape pens does differ – as does the smoking style of users. Some people take tiny “sips” throughout the day, others puff on them like cigars.

Do e-cigs cause cancer?

Nicotine on its own doesn’t cause cancer, but the chemical is highly addictive and e-cigarettes feed that addiction. Bricker worries that instead of helping smokers quit, the devices will actually encourage them to smoke more.

“People may become dual users,” he said. “They’ll smoke cigarettes and then smoke e-cigarettes when smoking is publicly prohibited. They may be smoking more or smoking the same. We don’t know.”

What about secondhand effects on kids?

A big unknown is what the effects are of inhaling propylene glycol vapor, which Bricker said does leave a residue on drapes and carpet and furniture.

“We don’t know the long-term effects of that getting in the blood system and how it might affect diseases and cancers,” he said. “We don’t know how it impacts children. Are e-cigarettes dangerous? We don’t know. They haven’t been around long enough and we haven’t studied the chemical compositions to see what impact they have on the body.”

Do they malfunction?

News reports have shown that the devices do occasionally malfunction, starting fires in homes and cars and causing serious injury to users or those around them. A North Carolina man trying to kick his smoking habit by using e-cigs was burned and temporarily blinded earlier this year after a device erupted in his face. And a charging e-cigarette set a 3-year-old child on fire, causing first- and second-degree burns.

Safety issues of this sort are nowhere to be found in the advertising and marketing campaigns for the devices, however.

What’s Big Tobacco’s role?

“I feel like I’m in a time machine,” said Bricker of e-cig campaigns which tend to feature young, beautiful people and celebrities. “All the memes of marketing cigarettes are now being adapted to market e-cigarettes. The message is ‘E-cigs are sexy! They’re fun! They’re sophisticated!’ And that’s a problem. They’re creating an enormous demand for a product that we don’t know enough about.”

The lucrative e-cig business is no longer dominated by small, scrappy start-ups. Big Tobacco has become a major player in the industry, responsible for the most popular e-brand, Blu, as well as many others.

Are kids really smoking them?

And e-cigs seem to be just as alluring as the real thing when it comes to kids. A survey-based study by the Centers for Disease Control and Prevention has already determined that e-cigarette use more than doubled among U.S. middle and high school students from 2011-2012, a trend CDC director Dr. Tom Frieden called “deeply troubling.”

Even more troubling, those numbers could be low, according to a recent New York Times story, because many young people think of the devices not as e-cigs, but e-hookahs or vape pens.

Whatever they’re called, e-cigs come in an array of eye-catching colors and candy flavors (think strawberry, watermelon, bubble gum, and grape soda), a marketing gimmick banned in conventional cigarettes because they appeal to young people.

What if I’m trying to quit smoking?

The bottom line? Both Bricker and Manders suggest sticking with tested methods to kick the smoking habit – and to rely on science, even if it’s slow in coming.

“It’s always a challenge because science moves in first gear and the market works in overdrive,” said Bricker. “But hopefully, people value science enough that they’ll be cautious about whether they want to buy these products. The prudent thing is to wait.”