Wednesday, August 11, 2010

Straight Talk About E-Cigarettes

Electronic cigarettes (e-cigarettes) pose important issues relevant to tobacco harm reduction. This post will review the facts about these products, which have been the subject of exaggerated claims by e-cigarette proponents and nicotine prohibitionists alike. As with most complex issues, the truth about e-cigarettes lies somewhere in between.

When users draw on them, battery-powered e-cigarettes vaporize a mixture of water, propylene glycol, nicotine and flavorings. Nicotine is one of the most intensively studied drugs in history; while it is highly addictive, it is not the primary cause of virtually any of the diseases related to smoking. In fact, long-term nicotine consumption is about as safe as that of caffeine. Propylene glycol is approved by the FDA for use in a large number of consumer products; it, too, is sometimes vaporized, forming artificial smoke in theatrical and other productions.

It is almost certain that e-cigarette use (also called vaping) is vastly safer than cigarette smoking, but this is based on limited scientific evidence. Some questions remain unanswered.

The health effects of long-term exposure of the respiratory tract to propylene glycol vapor are unknown, and unknowable. As a health professional, I am more comfortable recommending a product with a defined risk profile, where a clear risk-benefit analysis can be evaluated. That is why I have been a strong supporter of smokeless tobacco products as cigarette substitutes. I recommend these products knowing that we have 50 years of epidemiology documenting the extremely low level of health risks. E-cigarette consumers must understand that the safety of e-cigarettes can not be guaranteed, despite the likelihood that they pose but a tiny fraction of the health risks of regular cigarettes. But given the paucity of legitimate research, specific safety claims for e-cigarettes can not be made.

There is a lot of uncertainty with respect to the reliability of e-cigarettes, essentially all of which are imported from China. One of my colleagues ordered numerous products with the intent of performing some routine tests; many of these products did not function properly right out of the box. According to a recent clinical study of two brands (abstract here), “…neither of the electronic cigarettes exposed users to measurable levels of nicotine or [carbon monoxide]…” Not inhaling carbon monoxide is a good thing, but for addicted smokers, not getting nicotine may be a problem. Many e-cigarette users know that the devices often don’t deliver enough nicotine to satisfy them, so they re-load cartridges with even higher doses from commercially available concentrated solutions. Concentrated nicotine is dangerous, and this kind of experimentation is bound to lead to injuries.

The same study showed that “…both [brands] suppressed nicotine/tobacco abstinence symptom ratings.” This is impressive, because it indicates that e-cigarettes simulate the behavioral aspects of smoking and therefore may be successful in ways that no other smoking cessation product can match.

E-cigarette cartridges may contain hazardous contaminants. Last year, the FDA conducted laboratory tests on a few e-cigarette cartridges. Although the tests were biased and flawed (as I discussed here), they found in one cartridge traces of diethylene glycol, a poisonous impurity found previously in propylene glycol (reported here).

Consumer products should be free of contaminants. Cartridges, as well as the hardware, should be subjected to independent quality control testing. The FDA tests underscored the need for regulatory oversight. This could be accomplished if the FDA regulated e-cigarettes as recreational tobacco products under authority from the Tobacco Act. Instead, the FDA is attempting, inappropriately according to one federal judge, to regulate them as drug-delivery devices (discussed here). That would effectively remove them from the American market, leaving hundreds of thousands of e-cigarette users with no satisfactory alternative to tobacco combustion.

There is no justification or scientific rationale to ban e-cigarettes. Still, anti-tobacco extremists are campaigning against them, claiming, entirely without proof, that they are a starter tobacco product for children. As with all tobacco products, they should not be available to minors.

Another battle rages over whether e-cigarettes can be used safely indoors. Some militant users object to any indoor restrictions, while prohibitionists claim that second-hand vapor is annoying and/or toxic. The latter claim is preposterous, but e-cigarette users who are courteous and respectful toward bystanders are likely to lead longer, healthier and less stressful lives.


Anonymous said...

Nice article, thanks Dr Brad. One of the more sensible ones on the 'safety' issue.

People who learn about technique with support on forums and vaper communities appear to be a lot more likely to be successful. I think that's because the technology isn't a straight swap from lighting a cig to drawing on an ecig, there are important strategies to master to make vaping satisfying.

It does seem like luck that nobody has died from vaping, but poisoning numbers from nicotine have never been very high except for medical products. 42 deaths in the US from NRT since 2004 and none from ecig supplies yet.

It may suit vested interests to go for tobacco classification in the States but it's not going to do an awful lot for consumers. Considering your tobacco control high priests are anti-harm reduction, they'll likely destroy the product anyway. The long term plan appears to be about handing a monopoly for all nicotine sales over to pharm companies by closing the open market and then removing it from tobacco. So even if you win you lose when you accept only those two options.

It's a pity there wasn't much thought put into mobilising consumers to appeal for a fair regulatory system for all recreational drugs and linking up with other substance users who have had their drugs driven underground.

Commercial interests or control freaks will probably win in the short term but public opinion sticks around for the long haul.

Vive Le RĂ©sistance!

Unknown said...

Many e-cigarette users look forward to the day that the FDA does it's job and starts to regulate e-cigarettes for quality and safety. We are also so keen to understand the risks of indoor use that the product users themselves have taken the unusual action of organizing and funding an indoor air quality test. You can find more information and contribute to the test at:

Trails123 said...

Thanks for a balanced perspective Dr. Brad. Seems, like any hot topic, there are extremists on both sides of the E Cigarette debate. I believe the Anti E Cigarette types are more apt to argue delusional, baseless points though; after all, E Cigarette consumers have a vested interest and are more willing to do complete research rather than be led around by the nose. Any fool can parrot the FDA company line; whether it has merit or not!

I've been using an E Cigarette in place of smoking since December 6, 2009. As soon as I tried one, I stopped smoking on the spot; this after 40 years of smoking two packs a day. The improvement in my health, particularly my ability to breathe, speaks for itself.

E Cigarettes have been on the market (worldwide) going on seven years now. Millions of E Cigarette consumers and not a single report of serious illness or injury connected to them. Compare and contrast this with Chantix! I imagine the FDA, Big Pharma, and Anti-Smoking (Tobacco) Organizations will celebrate the day a Poster Child arrives on the scene (real or created) to add validity to their disinformation drives.

So I’m to fear E Cigarettes, go back to smoking (I like nicotine), and wait until the FDA does some scant study using cherry picked participants before considering continuing my E Cigarette usage; I think not. There are plenty of completed studies (which the FDA Et al. ignore) supporting E Cigarettes are magnitudes safer than smoking. By not smoking, I may be around long enough to see the outcome of much longer term studies from multiple sources!

Spike said...

I am relieved to see so many people who support the concept of harm reduction and I am thankful to know the truth. It has been hidden from the smokers for way too long! Thank you Brad for speaking the truth.

SPWS said...

The invention of electronic cigarettes might be the solution for healthier smoking. On the other end, I agree with you that further studies are needed before it can be proven safe.
e cigarette reviews

Joye 510 said...

I have been seeing lots of electronic cigarettes in bars in my place. I think this is a nice start for people to avoid those traditional cigarettes.

DonnyD said...

Great article. The jury is still out on e-cigs. While they may be safer than traditional cigarettes, that's not to say that they are completely safe. I, for one, will be following the e-cig industry with a watchful eye.