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.