E-Cigarettes: Clearing the Air

Electronic cigarettes, otherwise known as e-cigarettes, have been sweeping the nation since their introduction in 2007 and have grown into a $2-billion market.¹ According to the Mayo Clinic, nearly 6% of all US adults and 21% of US adult smokers have tried e-cigarettes. Among US middle and high school students, 50.3% are aware of e-cigarettes and those who report use of e-cigarettes has increased from 4.7% in 2011 to 10.0% in 2012 (Online Figure²).

Safety claims of e-cigarettes have been circulating, with the majority of the published information, which can be misleading, coming from the manufacturers of e-cigarettes. This article discusses 5 myths about e-cigarettes and the facts behind each one.

Myth 1: e-Cigarettes Are Safer than Conventional Cigarettes

With the growing popularity of e-cigarettes comes the perception that they are safer than tobacco cigarettes—but this is not necessarily the case. Although there is insufficient evidence to provide a definitive answer, according to the National Institute on Drug Abuse, there are many reasons why e-cigarettes may not be a safer alternative. To begin, e-cigarettes and cigarettes contain nicotine, a highly addictive drug that can lead to dependence regardless of the way it is inhaled.³

Some e-cigarette manufacturers claim their products are free of nicotine. However, the FDA conducted a laboratory analysis and found low levels of nicotine in 17 (94%) of 18 of the cartridges tested.⁴ In addition, although e-cigarettes do not produce tobacco smoke, they do contain other potentially harmful chemicals, including formaldehyde and acetaldehyde.³ Furthermore, the long- term health consequences of e-cigarette use remain unknown.⁵

In 2009, the FDA also announced findings of a laboratory analysis of ecigarette samples. The results were positive for carcinogens and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze.6 E-cigarette manufacturers have attempted to debunk these results.

Myth 2: e-Cigarettes Can Help Individuals Trying to Quit Smoking

The American Lung Association (ALA) is concerned about claims that e-cigarettes are helping smokers to quit. The FDA Center for Drug Evaluation and Research has not deemed e-cigarettes to be safe and effective for helping smokers to quit.⁵ The ALA reports that many consumers use e-cigarettes and conventional cigarettes simultaneously, instead of quitting, which is a concern. In 2013, 76.8% of people who used e-cigarettes were found to also smoke conventional cigarettes.⁷

Despite many smokers using ecigarettes to cut back on conventional smoking, they are still being exposed to tobacco and actually prolonging their exposure to it. Although reducing the number of cigarettes smoked per day is beneficial to health, even exposure to a low level of tobacco carries a significant risk. No level of tobacco exposure is safe. Smoking cessation should always be recommended.²

According to a review published in Mayo Clinic Proceedings, the American Heart Association (AHA) suggests clinicians not recommend e-cigarettes as primary cessation aids and that patients using e-cigarettes should be encouraged to designate a quit date for them. However, the AHA also suggests that if initial smoking cessation treatment fails or a patient has refused conventional treatments and wishes to use e-cigarettes to aid quitting, it “is reasonable to support the attempt.”²

Myth 3: e-Cigarettes Are Regulated

According to the National Institute on Drug Abuse, e-cigarettes are not regulated by the FDA. This is mainly because they are not marketed as tobacco products or as devices having a therapeutic purpose. Currently, there are no accepted measures to confirm the purity or safety of e-cigarettes. In addition, the liquids used in e-cigarettes are not regulated.³

Myth 4: The Flavorings in e- Cigarettes Are Safe

By January 2016, e-cigarettes were available in 7764 flavors, including Chocolate Treat, Snappin’ Apple, and Vanilla Dreams. The main focus of concern has been nicotine, but what about the potential toxic effects of the inhaled flavorings?¹

In a Journal of the American Medical Association article, Barrington-Trimis et al stated, “Recent in vitro studies found that the cytotoxic effects of e-liquids were largely restricted to flavoring components.”1 In addition, these researchers suggest that the potential toxic effects from inhaled flavorings are largely unrecognized.¹

Myth 5: e-Cigarettes Do Not Produce Harmful Secondhand Smoke

In general, e-cigarettes contain nicotine and other harmful substances that are inhaled by users. Unfortunately, little is known about how the vapors affect bystanders.⁷ Recent study results showed e-cigarettes may involuntarily expose bystanders to nicotine. Further research is warranted to test exposure to the toxic constituents of the vapors emitted from e-cigarettes and their effects on health.⁸

Conclusion

The ALA has voiced concerns about e-cigarettes being a “gateway” to conventional cigarettes⁵ and has referred to a recent study that evaluated middle school and high school students. The study revealed “an alarming increase in the number of middle and high school students who used e-cigarettes but never smoked a cigarette.” The study also found that these youths were almost 2 times more likely to intend to begin smoking regular cigarettes compared with youths who had never used e-cigarettes.⁹

The alarming increase is likely a result of a combination of factors, such as the following:

• Age verification is not required to purchase e-cigarettes online; they are readily accessible to everyone, especially youths. In 2015, a group of researchers measured the rate at which minors could successfully purchase e-cigarettes online in North Carolina: despite North Carolina’s 2013 e-cigarette age-verification law, the buy rate was 93.7% and none of the vendors were compliant with the e-cigarette age-verification law.¹⁰
• E-cigarettes come in many flavors, as previously mentioned; have attractive packaging; and are available to purchase online.6 In addition, there are nearly 500 brands. Therefore, the noticeable increase in the number of youths using e-cigarettes should not be a surprise.
• E-cigarettes have been promoted as appealing by movies, television, celebrities, and social media, and youths can be highly influenced by popular media.
• E-cigarettes may be appealing to many because they simulate the experience of smoking a cigarette and deliver nicotine to the lungs (Online Table²).

Table: The Appeal of e-Cigarettes

● Address the psychopharmacologic, social, and behavioral aspects of smoking

● Simulate the experience of smoking a cigarette:

â—‹ The vapor simulates tobacco smoke

â—‹ Handling the device simulates the hand-to-mouth experience of cigarette use

â—‹ The flavors simulate or enhance the taste of cigarettes

● Deliver nicotine to the lungs to relieve nicotine withdrawal symptoms

● Are perceived to help quit or reduce smoking

● Are perceived to be a healthier and safer alternative to conventional cigarettes

● Bypass smoking restrictions

● Decrease costs associated with tobacco dependence

^{Adapted from reference 2.}

An online search for e-cigarettes presents endless information from e-cigarette manufacturers. Most of this information is biased and inaccurate. Health care professionals should be aware of the kind of misinformation their patients may be seeing and be prepared to counsel patients on the efficacy of e-cigarettes as a smoking cessation treatment and on the associated risks.

Dr. Anyssa Garza received her doctor of pharmacy degree from the University of Texas at Austin. She is currently working as the director of the Life Sciences Library at RxWiki, where she continues to build her practice on the fundamental belief that providing patients with medication information and medical knowledge contributes significantly to the quality of care they receive and improves quality of life and health outcomes. Her work focuses on educating patients and providing them with the resources needed to navigate the overwhelming and complex health system. Before RxWiki, she was director of pharmacy for a Central Texas Department of Aging and Disability facility.

References

• Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in electronic cigarettes: an unrecognized respiratory health hazard? JAMA. 2014;312(23):2493-2494. doi: 10.1001/jama.2014.14830.
• Ebbert JO, Agunwamba AA, Rutten LJ. Counseling patients on the use of electronic cigarettes. Mayo Clin Proc. 2015;90(1):128-134. doi: 10.1016/j.mayocp.2014.11.004.
• Drug facts: electronic cigarettes (e-cigarettes). National Institute on Drug Abuse website. drugabuse.gov/sites/default/files/drugfacts_e-cigs_9_15.pdf. Published August 2015. Updated August 2015. Accessed October 18, 2015.
• American Lung Association statement on e-cigarettes. ALA website. lung.org/our-initiatives/tobacco/oversight-and-regulation/statement-on-e-cigarettes.html. Updated March 2015. Accessed September 17, 2015.
• Summary of results: laboratory analysis of electronic cigarettes conducted by FDA. FDA website. www.fda.gov/NewsEvents/PublicHealthFocus/ucm173146.htm. Updated April 22, 2014. Accessed October 20, 2015.
• FDA and public health experts warn about electronic cigarettes [news release]. Silver Spring, MD: FDA; July 22, 2009. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm173222.htm. Accessed October 18, 2015.
• Myths and facts about E-cigarette. American Lung Association website. lung.org/stop-smoking/smoking-facts/myths-and-facts-about-e-cigs.html. Accessed September 17, 2015.
• Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine Tob Res. 2014;16(6):655-662. doi: 10.1093/ntr/ntt203.
• E-cigarette use among non-cigarette smoking youth triples [press release]. Washington, DC: American Lung Association; August 25, 2014. lung.org/about-us/media/press-releases/e-cigarette-use-triples-in-nonsmokinr-youth.html. Accessed September 17, 2015.
• Williams RS, Derrick J, Ribisl KM. Electronic cigarette sales to minors via the Internet. JAMA Pediatric. 2015;169(3):e1563. doi:10.1001/jamapediatrics.2015.63.