by Eden V. Wells, MD, MPH, FACPM
I was visiting my family during a reunion a few months ago, and came face-to-face with what I now refer to as the “e-cigarette dilemma”. A family member, who is in his mid-50’s and has smoked since his teens, was using an e-cigarette, and stated he has been doing so over the last year. He uses a cinnamon flavor. I certainly was glad to see the “vaping” (the term used for e-cigarette use) family member cutting down (in fact, he has not smoked a regular cigarette in a long time), and complimented him on his efforts.
But suddenly, the questions about e-cigarettes that have come to me as matters of policy became quite personal. Do I think that use of an e-cigarette is healthier than that of a traditional cigarette? Can I say that the use of an e-cigarette is healthy? What do we know about e-cigarettes effects on others exposed to the vapor?
What is known is that use of tobacco products are the source of morbidity preventable deaths in the US and across the globe. 1,2 Smoking causes more than 480,000 deaths each year in the United States.2,3 Nearly 18 of every 100 U.S. adults aged 18 years or older (17.8%), or 42.1 million adults currently smoke cigarettes; current smoking has declined from 20.9% in 2005.3
Yet, while traditional cigarette smoking has decreased, other uses of tobacco/nicotine products are on the rise. In fact, e-cigarettes are marketed as smoking cessation devices or alternatives to traditional cigarettes.4 A 2014 study showed that e-cigarette use was especially prominent among current and former cigarette smokers.5 In 2014, 12.6% of adults had ever tried an e-cigarette even one time, and the majority were young adults aged 18-24 years of age.6
What is particularly worrisome is the increased use of e-cigarettes utilized by adolescents, who are smoking traditional cigarettes less, but from 2011 to 2014 substantial increases were observed in e-cigarette and hookah use among middle and high school students (an estimated 2.4 million e-cigarette youth users).7 Per the Centers for Disease Control and Prevention, use of tobacco in any form, whether combustible, noncombustible, or electronic, is unsafe; further, nicotine exposure during adolescence, might have lasting adverse consequences for brain development and causes addiction, which may lead to sustained use of tobacco products.7
Currently, the U.S. Food and Drug Administration (FDA) Center for Tobacco Products regulates cigarettes, cigarette tobacco, roll-your-own tobacco, and smokeless tobacco. In 2015 FDA issued a proposed rule that will extend its authority to cover additional tobacco products such as e-cigarettes.8 The recommendation to have e-cigarettes regulated as a tobacco product is strongly supported by the American Thoracic Society, the American College of Physicians, and the American Academy of Pediatrics, among others.9,10,11
These recommendations are based upon the following:
- E-cigarettes are NOT an FDA-approved quit tobacco device.12
- E-cigarettes are NOT a safe alternative to other forms of tobacco.12
- E-cigarettes may be particularly attractive to youth due to their novelty.12
- Recent studies show that use of e-cigarettes may encourage traditional cigarette use by adolescents.13
- The number of calls to poison centers involving e-cigarette nicotine liquids rose from one per month in September 2010 to 215 per month in February 2014.14
Yet, while e-cigarette use has skyrocketed over the last few years, much remains unknown about the effects on individual or population health, as no data exists yet regarding long-term neoplastic, respiratory, or cardiac risks.15 So while I applaud my family member and others for looking for ways to cut back or quit tobacco use, long-term studies are needed to determine the safety and efficacy of e-cigarettes. Studies such as those are vital to informing public health and healthcare providers about the health effects of aerosolized substances comprising flavored nicotine liquids, and whether use of e-cigarettes definitively decreases the use of traditional cigarettes.15
REFERENCES
1. Bartter T. Electronic Cigarettes: Aggregate Harm. Annals of Internal Med. 2015; 163(1):59-60.
2. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html Accessed November 23, 2015.
3. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults—United States, 2005–2013. Morbidity and Mortality Weekly Report 2014;63(47):1108–12.
4. Grana RA, Ling PM. “Smoking revolution”: A content analysis of electronic cigarette retail websites. Am J Prev Med 46(4):395–403. 2014.
5. King BA, Patel R, Nguyen K, et al. Trends in Awareness and Use of Electronic Cigarettes among U.S. Adults, 2010-2013. Nicot & Tob Res. 2015; 17 (2): 219-227
6. Schoenborn CA and Gindi RM. NCHS Data Brief. Electronic Cigarette Use Among Adults: United States, 2014. October 2015, Number 217, Available at: http://www.cdc.gov/nchs/data/databriefs/db217.htm. Accessed November 23, 2015.
7. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students — United States, 2011–2014. MMWR 2015; 64(14);381-385.
8. US Federal Drug Administration. E-Cigarettes. Available at: http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm. Accessed November 23, 2015.
9. Leone FT, Douglas IS. The emergence of e-cigarettes: a triumph of wishful thinking over science [Editorial]. Ann Am Thorac Soc. 2014; 11:216-9.
10. Crowley RA, for the Health and Public Policy Committee of the American College of Physicians. Electronic nicotine delivery systems: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162:583-4
11. The American Academy of Pediatrics. The American Academy of Pediatrics Issues Sweeping Recommendations on Tobacco and E-Cigarettes - See more at: https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Tobacco-and-E-Cigarettes, October 25, 3015. Available at: https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Tobacco-and-E-Cigarettes.aspx. Accessed November 23, 2015.
12. Michigan Department of Health and Humans Services. A Primer on Emerging Tobacco Products, Available at: http://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2973-340369--,00.html. Accessed November 23, 2015.
13. Lauren M. Dutra LM, Glantz SA.Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents, A Cross-sectional Study. JAMA Pediatr. 2014;168 (7):610-617
14. Centers of Disease Control and Prevention. Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014. 2014; 63(13);292-293.
15. Drummond MB. Electronic Cigarettes: Perhaps the Devil Unknown Is Better Than the Devil Known. Annals of Internal Med. 2015; 163(1): 61-62