Electronic Nicotine Inhalers (a.k.a. e-cigarettes): Worth a try?

It depends.

by By Jim Buehler, professor of health management and policy, Drexel University

Published Feb. 11, 2014, 6:30 a.m. ET

It's been hard to avoid stories in the news about "electronic cigarettes"—battery-powered devices that in many cases look like regular cigarettes but instead deliver a vaporized mix of nicotine, flavor additives, and traces of the chemicals left over from extracting nicotine from tobacco. Much of the attention to e-cigarettes arises from debates about whether their manufacture, marketing, sales, and use should be subject to the same federal, state, and local regulations and restrictions as those that govern other tobacco products.Depending on your attitudes towards smoking, government health regulations, and your source of news, you might believe that e-cigarettes are:

A way for smokers to satisfy their appetite for nicotine while avoiding the hazards of tobacco smoke;
A socially acceptable alternative to smoking (they emit water vapor, not smoke) that should be permitted in public;
An alternative to nicotine patches or gum that can help smokers quit or reduce their dependence on nicotine (by turning them into "vapers");
A way for "big tobacco" to bypass tobacco regulations, offset financial losses resulting from reductions in smoking, and lure a new generation into nicotine addiction;
A threat to decades of progress in reducing tobacco use;
Something that health advocates should endorse as a safer alternative to smoking—a "harm reduction" program, like those that provide clean needles and syringes to drug users to reduce exposures to HIV and other infections;
A product with undocumented benefits and risks;
Some combination of the above.

While public health advocates are universally committed to reducing smoking, their reaction to the emergence of e-cigarettes has been mixed. Some have called for an outright ban on e-cigarettes until studies have been conducted to document their risks and benefits—a policy that is unlikely to be enacted. Many view e-cigarettes through the same lens as regular cigarettes, remain deeply distrustful of the tobacco industry given its well-documented legacy of concealing information about the risks of smoking, and advocate strong regulations that would limit advertising and make it difficult for teens to purchase e-cigarettes. This position is embodied in statements like one by Erika Seward of the American Lung Association, who was quoted by ABC News as saying, "With e-cigarettes, we see a new product within the same industry—tobacco—using the same old tactics to glamorize their products. They use candy and fruit flavors to hook kids." Other health advocates view e cigarettes through the "harm reduction" lens and favor regulation of e-cigarettes as "drug delivery devices." For smokers who are unable or unwilling to abandon their nicotine addiction, this group argues that, despite unknowns about the consequences of inhaling e-cigarette vapors, using e-cigarettes must be less dangerous than inhaling tobacco smoke. Both positions - a ban and regulation as a drug delivery device - are vehemently opposed by e-cigarette-makers.

The e-cigarette industry strongly denies that it markets its products to young people, arguing that there are plenty of adult smokers to convert to their product. Regardless, a growing number of teens are giving them a try. A recent report from the Centers for Disease Control and Prevention (CDC) notes that the percentage of high school students who have tried e-cigarettes doubled from 4.7% in 2010 to 10% in 2012. CDC estimates that there are nearly 1.8 million middle and high-school students who have used e-cigarettes, including 160,000 who have never used regular cigarettes, raising a "serious concern" because of the "negative impact of nicotine on adolescent brain development, as well as the risk for nicotine addiction." We know that most adult smokers started as teens, but we don't know yet if the growing number of teens who are trying e-cigarettes will remain e-cigarette users, quit using any form of nicotine, or be drawn into smoking for the first time.

E-cigarette manufacturers—many independent, but increasingly subsidiaries of major tobacco companies— are willing to accept regulations that require informing consumers about the contents of their products and restrict sales to minors. But they argue against treating e-cigarettes like other tobacco products or "drug delivery" devices—moves that would curtail advertising or require greater documentation of their safety and benefits. In a full-page "open letter" published recently in the New York Times, the chief executive officer of one of the largest e-cigarette companies dismissed as a "myth" the notion that "FDA regulation of electronic cigarettes will protect consumers." This claim is made largely on the grounds that regulations would "limit their availability" to consumers and require costly and lengthy approval procedures that would stifle innovation in developing e-cigarette products.

Which leaves us to ask: Who do you trust more to protect the health of consumers: the FDA or the e-cigarette manufacturers and their champions and investors in the tobacco industry?

In addition to the health effects of inhaling nicotine and other contents in the e-cigarette "juice," there have been isolated stories in the news about injuries and fires arising from the explosion of e-cigarette batteries. These episodes appear to be related to modifications of e-cigarette batteries by enthusiasts seeking to enhance their "vaping" experience or to improper use of USB outlets in cars or computers to re-charge the e-cigarette batteries—mistakes that are contrary to manufacturers' instructions but apparently easy to make. So, if you are going to use e-cigarettes, at least be sure to read and follow the directions. In addition, there have been a few instances of small children getting ahold of their parents' e-cigarettes, chewing them, and drinking the nicotine-containing liquid. Like any product that could be harmful to children, e-cigarettes should be kept from their reach.

The Food and Drug Administration advises on its website that consumers "currently have no way of knowing whether e-cigarettes are safe for their intended use, how much nicotine or other potentially harmful chemicals are being inhaled during use, or if there are any benefits associated with using these products." As we await further evidence about the safety, benefits, and risks of e-cigarettes and the resolution of the regulation debates, one commentator reminds us of the old adage, buyers "beware." That's good advice.

James W. Buehler, M.D., is a professor in the Department of Health Management and Policy of the Drexel University School of Public Health. This post was informed by contributions from students in his course, "Current topics in public health practice." For more information about e-cigarettes, see the Q&A's posted by the Philadelphia Department of Public Health.