“I’ve seen a lot of puzzled people,” Alexander V. Prokhorov, MD, PhD, said, referring to people who see others using electronic or e-cigarettes. That puzzlement can go beyond wondering why people are smoking in public places and whether they are breaking the law, or just being annoying, to questions such as what are they smoking and how does it affect bystanders and the environment?
E-cigarettes, as defined by the FDA, “are battery-operated products designed to deliver nicotine, flavor, and other chemicals. They turn nicotine, which is highly addictive, and other chemicals into a vapor that is inhaled by the user.”1 There are a lot of unknowns about e-cigarettes and what chemicals they contain, and those unknowns and the increasing popularity of e-cigarettes, particularly among young people, have Dr. Prokhorov and many others concerned. Dr. Prokhorov is Director of the Tobacco Outreach Program, Co-director of the e-Health Technology Program, and Professor in the Department of Behavioral Science at The University of Texas MD Anderson Cancer Center in Houston.
“We really don’t know what is in e-cigarettes,” said Dr. Prokhorov. “There are so many different factories abroad that manufacture these products, how do we know that the quality is consistent and the amount of nicotine is consistent? We don’t. That’s the problem.”
The FDA does not currently regulate e-cigarettes unless they are marketed for therapeutic purposes. And, “There are currently no electronic cigarettes that are FDA-approved for therapeutic purposes,” according to an FDA spokesperson.
“The FDA intends to propose a regulation that would extend the agency’s ‘tobacco product’ authorities—which currently only apply to cigarettes, cigarette tobacco, roll-your-own tobacco, and smokeless tobacco—to other categories of tobacco products that meet the statutory definition of ‘tobacco product,’” the spokesperson wrote in response to an e-mail inquiry from The ASCO Post. Although October 2013 had been listed in an FDA agenda and reported by the media as the estimated date for issuing a proposed rule, the FDA “doesn’t rule out the publication of the proposed rule happening before or after a date. The agency can’t speculate on timing,” according to the FDA spokesperson.
In a “Room for Debate” feature in The New York Times,2 Anne Joseph, MD, MPH, Wexler Professor of Medicine at the University of Minnesota, and President of the Society for Research on Nicotine and Tobacco, noted that e-cigarettes are “more accurately called electronic nicotine delivery systems, or ENDS.” According to Dr. Joseph, “A few studies demonstrate that ENDS deliver lower levels of many tobacco toxins than traditional cigarettes, but dangerous chemicals in addition to nicotine, like acetaldehyde, a natural substance found in tobacco, and benzene, a petroleum-based chemical, can certainly be measured in their emissions. The amount of these substances varies considerably because e-cigarettes are still unregulated.”
E-cigarettes also contain flavorings, such as cherry, bubble gum, and chocolate, that appeal to young people. “Every time a new flavor is introduced, you really don’t know what it is. What kinds of chemicals are used? If inhaled, what do they do to the body? We don’t know. I certainly hope that the FDA would pay close attention to regulating these substances,” said Dr. Prokhorov. “I am not saying that e-cigarettes are more harmful that conventional cigarettes; by no means, absolutely not,” Dr. Prokhorov said. “But if manufacturers use some kind of unsafe substance to make an e-cigarette a certain flavor, it could be pretty harmful without us even knowing.”
Gateway to Smoking
“E-cigarette experimentation and recent use doubled among U.S. middle and high school students during 2011 to 2012, resulting in an estimated 1.78 million students having ever used e-cigarettes as of 2012,” according to survey data reported by the Centers for Disease Control and Prevention.3 “Moreover, in 2012, an estimated 160,000 students who reported ever using e-cigarettes had never used conventional cigarettes.” Asked if that finding indicates that e-cigarettes may serve as a gateway to smoking traditional cigarettes, Dr. Prokhorov replied, “Absolutely.”
New and high-tech products tend to attract young people, he said, adding, “This is not the first attempt of the tobacco industry to [market] an alternative cigarette that would be high-tech.” A product introduced a few years ago relied on heated, but not burning, tobacco, to imitate the smoking process, but “that one was a failure, I guess mainly because it didn’t produce any kind of cigarette smoke, as in this case,” meaning the vapor produced by e-cigarettes. “But this time it looks like they succeeded. [E-cigarettes] have all of these elements; they have the battery; they have the heating element; they have the cartridge with nicotine and flavoring; and it imitates the smoking process. There is a smoke-like ritual. You actually inhale something that looks like smoke and exhale something that looks like smoke. Essentially you get what you want to get—you get your nicotine and you get your ritual,” said Dr. Prokhorov.
“E-cigarettes come in all kinds of shapes and sizes and some of them look very much like cigarettes, with a white part and a filter part. Others look nothing like cigarettes,” Dr. Prokhorov explained. “They look like some sort of contemporary, super futuristic-looking gadgets. Kids are enticed by these things. They like to own cool gadgets.”
All this can “lead to some kids who would never think about starting cigarette smoking to try something that is perceived to be much less harmful. And that is how these e-cigarettes are positioned—as virtually harmless,” Dr. Prokhorov said, but “e-cigarettes could be an introduction to the whole tobacco world for them.”
Nicotine Is Still a Poison
The nicotine in e-cigarettes and the possibility of a quick descent into nicotine dependence concern Dr. Prokhorov greatly. “We used to think that nicotine dependence develops over a reasonably long period of time, but there are some studies that claim that with a certain genetic makeup, you can actually develop nicotine dependence very quickly,” he said. “Once you develop nicotine dependence, if you are not fully satisfied with e-cigarettes, it makes it an easier experience to switch to conventional cigarettes.”
Nicotine, he noted, “is still a poison. A certain amount of nicotine can kill you. If you overdose, it can kill you. That brings up another issue. Kids sometimes do silly things,” like issue each other extreme challenges. So while e-cigarettes may not be as harmful as conventional cigarettes, “I am still concerned by extended use of these products by young people,” Dr. Prokhorov said.
A recent study in the Lancet4 reported that e-cigarettes can work at least as well as nicotine patches in helping smokers to quit. “But when you look at the results, one-third of e-cigarette users continue to use e-cigarettes, whereas 8% of patch users continue to use patches at 6 months after the quit date, when in fact the “treatment” in the study was supposed to end 11 weeks after the quit date. To me, that suggests that e-cigarettes can delay quitting. Instead of quitting cigarettes over a certain period of time, people continue using these nicotine products,” said Dr. Prokhorov.
He acknowledged that it is possible that someday e-cigarettes might be shown to be an effective aid for individuals interested in quitting smoking traditional cigarettes. But until the products are regulated, there will always be unanswered questions about safety of the manufacturing practices for the products.
“We have to be very careful about the potential downsides of e-cigarettes and certainly research this as carefully as we can to see if they are helpful to quitting smoking,” Dr. Prokhorov said. “I am a researcher and I would like to see convincing evidence that the e-cigarette, as a nicotine delivery device, is both safe and effective before marketing it as a cessation aid is permitted. Although one study showed comparable results as nicotine replacement therapy, it is important to note that the nicotine medications have been used for decades and considered to be a “clean” form of nicotine. In contrast, e-cigarettes deliver not only nicotine but also other potentially harmful chemicals,” he added.
“There is a lot of debate going on within the tobacco control community about this issue,” Dr. Prokhorov acknowledged. Some advocate manufacturing only e-cigarettes and doing away with traditional cigarettes. “My big problem with that is that I haven’t seen any document that would tell me that as of a certain date, the production of conventional cigarettes is going to stop. As long as we have conventional cigarettes available, there is always the danger of starting with e-cigarettes and switching to regular cigarettes.”
Bad Old Days
Some states have indoor smoking restrictions for e-cigarettes as well as conventional cigarettes, but according to Dr. Prokhorov, there is not much evidence of harmful effects caused by second-hand vapor from e-cigarettes. “Certainly there is no comparison with conventional cigarettes,” he said. “But the problem I see here is, we just reached a level where society has certain rules, and a certain vision, a certain perception of smoking in public places,” and using e-cigarettes in public places “is reminiscent of the times” of smoke-filled hallways, theaters, trains, and planes.
Also reminiscent of the smoky days and haze of yore are the advertisements for e-cigarettes, some featuring celebrities and glamourizing smoking. “Kids are watching,” Dr. Prokhorov said. ■
Disclosure: Dr. Prokhorov reported no potential conflicts of interest.
1. U.S. Food and Drug Administration: Electronic cigarettes (e-cigarettes). Last updated April 25, 2013. Available at http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm. Accessed October 2, 2013.
2. Joseph AM: Room for debate: More trials, more disclosure. New York Times, August 20, 2103. Available at www.nytimes.com. Accessed October 2, 2013.
3. Notes from the field: Electronic cigarette use among middle and high school students—United States, 2011-2101. MMWR Morbid Mortal Wkly Rep 62:729-730, 2013.
E-cigarettes are in the news, in advertising, and in stores, and because their public use is still largely unregulated, they may be in your face. Being prepared to answer questions about their use may help patients make wise decisions.
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