This one is for you Eric and Marcia!!!-A.M.
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| Human World on Sep 12, 2013
Image Credit: Michael Dorausch

Image Credit: Michael Dorausch
Two new studies showcase the pros and cons of electronic cigarettes.

In 1988 R. J. Reynolds Tobacco Company launched what was to become an epic product fail: the Premier cigarette. Marketed as a “smokeless” cigarette, Premier cost some $800 million to develop and offered users the pleasure of inhaling vapor produced by heating an aluminum-encased tobacco pellet. The resulting cigarette was challenging to light, difficult to inhale, and purportedly tasted like a medley of burning plastic and charcoal. RJR spokespeople argued that Premier was an acquired taste, but most smokers never made it past the first few puffs and the ill-fated cigarette was pulled from the market less than a year after its debut. You’d think that would have been the end of the quest for a “healthier” cigarette, but manufacturers plodded on. And 25 years later, it seems that a newer product – the electronic cigarette – is finally catching on. Though they’ve been available since the mid 2000s, e-cigarettes are suddenly everywhere. Last month I saw a guy pull one out on an airplane. Seriously. A flight attendant quickly came over to inform him that this wasn’t allowed, but the two lingered, chatting about their preferred e-cigarette brands and the exciting new flavors they planned to bust out once safely back on the ground.

As e-cigarettes have become more visible, so have the dueling editorials claiming that they will alternately save the lives of existing smokers or undo several decades of effort to reduce smoking. With no long-term studies on the health of e-cigarette users, the safety of these products is difficult to determine. The basic mechanism is designed to eliminate the health risks inherent in burning tobacco. E-cigarettes electronically heat a nicotine-and-flavor-infused liquid into a vapor, which is then inhaled into the lungs. (You could also think of it as a battery-powered, crack-free crack pipe, though I’m guessing that concept would be harder to market.) The liquid, or “vaporizing agent” used is typically propylene glycol or glycerin, both of which are considered reasonably safe to ingest orally (note: that doesn’t necessary translate into safe to inhale) though a 2009 FDA analysis found a few nastier chemicals in the mix as well. Still most people can agree that e-cigarettes are probably safer than conventional cigarettes but less safe than no cigarettes. Much of the help-to-harm ratio will thus be determined by how they are used. Will e-cigarettes help people quit smoking? Will they replace conventional cigarettes? Or will they spawn a new generation of e-smokers? (Or “vapers” to be more accurate, since there’s no actual smoke involved.*)

Some e-cigarettes look like plain old tobacco cigarettes. Image: Jakemaheu.

Some e-cigarettes look like plain old tobacco cigarettes. Image: Jakemaheu.

E-cigarettes and quitting nicotine

Earlier this week, the Lancet published the first reasonably large randomized trial testing the efficacy of e-cigarettes as an aid in quitting smoking against that of a more standard smoking cessation tool – the nicotine patch. 657 smokers who wanted to quit were accepted for the study and randomly assigned to groups provided with either e-cigarettes or nicotine patches for 13 weeks, while they attempted to abstain from conventional smoking. Of the e-cigarette recipients, a portion were given “placebo” e-cigarettes containing no nicotine. The short version of the results is that e-cigarettes fared at least as well as the patch in helping smokers quit or reduce their use of conventional cigarettes, which sounds like good news. But the details are somewhat less encouraging.

Others look more like, hmm, fountain pens? Image: Witzmano.

Others look more like, hmm, fountain pens? Image: Witzmano.

For starters, the overall quit rates were pretty lousy. At the six month follow-up only 7.3% of the nicotine e-cigarette group and 5.8% of the patch group were still conventional smoke free.** That’s lower than the authors expected and lower than nicotine patches have fared in previous studies. This being an e-cigarette trial, it’s possible that the people assigned to the nicotine patch were hoping to try these exciting e-cigarettes they’d been hearing about and got discouraged once they found out the were in the patch group. I’m also a little skeptical about the use of the nicotine-free electronic cigarette as a placebo. A big part of the appeal of conventional smoking is whole inhaling/exhaling action, not just the nicotine. Thus a nicotine-free e-cigarette is hardly the same kind of placebo as a sugar pill in a drug trial. And indeed that “placebo” group wasn’t that far behind in quitting, with 4% still abstaining from conventional smokes at the 6-month mark.

Of the (majority) participants who failed to quit after 6 months, nicotine e-cigarette users did fare better than patch users in at least reducing their total daily number of conventional cigarettes smoked. The authors note that the e-cigarette recipients were also much more enthusiastic about their product than the patch group. Sure, they would totally recommend it to a friend! In fact, they liked e-cigarettes so much that a third of them were still using the product after 6 months (compared to just 8% of the patch group) even though the study only called for about 3 months of e-cigarette use. Do you see the issue here? E-cigarettes seem better suited for getting people to switch products rather than to quit smoking/vaping altogether. Still, if we’re going for a lesser-of-two-evils thing, this isn’t necessarily bad news. If smokers want to switch from combustible to vaporized nicotine products, maybe we should encourage it. But then there’s this…

E-cigarettes and starting nicotine

A few days before the Lancet study appeared, the CDC released a report on e-cigarette use among teenagers in the U.S., and it’s a little worrying. The overall percentage of teens using these things is low, but the numbers are rising quickly. In 2012 6.8% of student in grades 6-12 admitted to having tried e-cigarettes, up from 3.3% in 2011. And 2.1% were considered current e-cigarette users (having partaken of the product on more than one day in the past month), up from 1.1% in 2011. But here’s the potentially troublesome part: not all those who dabbled in e-cigarettes were also smoking conventional cigarettes. Of those who had only tried e-cigarettes, 9.3% had never smoked a regular tobacco cigarette. Among the current e-cigarette users, about three quarters also smoked conventional cigarettes, meaning one quarter were exclusively using e-cigarettes. This isn’t proof that e-cigarettes are a gateway to conventional smoking, as some have accused, as we don’t know which products teens tried first and whether or not the current e-cigarette-only users were previously conventional smokers. Though it certainly suggests that e-cigarettes might be attracting costumers who aren’t just looking for a way to reduce their conventional smoking.

I'm telling you, they're everywhere. Image: Alex Reshanov.

I’m telling you, they’re everywhere. Image: Alex Reshanov.

The CDC report fuels concerns that e-cigarettes, with their array of candy store flavors (in addition to boring tobacco flavor they also come in varieties like cream soda and banana split) might lure young people who would never have bothered with conventional cigarettes into a lifetime of nicotine addiction. And the “it’s just vapor” line of advertising makes it sound like the product is indisputably safe, even though the World Health Organization recommends against using it until more research is done. Check out this creepy ad featuring Jenny McCarthy singing the praises of a “guilt free” electronic cigarette. (Really, McCarthy? You’re afraid of routine vaccinations but inhaling a nicotine-laced vaporizing agent doesn’t raise any red flags?) I’m all for letting people make their own decisions, but they should understand that this is a product of undemonstrated safety and not just “healthy smoke” as I heard someone describing her e-cigarettes recently.

To ban or not to ban

In the midst of the swirling controversy, legislators and business owners are trying to figure out how to treat these increasingly popular products, which aren’t automatically included in existing smoking bans. It’s not such a straightforward decision. When traditional cigarettes were ousted from bars and restaurants across the country the main argument in favor of the ban was second hand smoke. People employed by these establishments, the reasoning goes, have as much right to work in a safe, smoke-free environment as anyone else. But with e-cigarettes that logic may not apply. We don’t have much data yet on the effects of second hand e-cigarette vapor. E-cigarettes aren’t even tobacco products, they’re “electronic nicotine delivery systems” (ENDS). Objections to e-cigarettes in public spaces thus far are largely aesthetic. When bans on conventional cigarettes first went into effect, many smokers were none too thrilled about getting kicked out into the cold every time they wanted a cigarette. But people adjusted and many even came to appreciate not having their clothes and hair reek of smoke when they got home from a night out. We’ve grown accustomed to our unscented businesses, and are understandably wary about having someone blowing cotton candy flavored vapor inches away from our face. Folks on the Internet claim the stink factor is much lower for e-cigarettes than conventional ones, but some of the flavor options sound genuinely revolting. I just found a website that offers flavors like bacon and Red Bull. Imagine getting stuck sitting between those two vapors at a crowded bar. Perhaps we can compromise and bring back the smoking section? Sorry, I mean the vaping section.

* The terminology of e-cigarettes will take some getting used to. Currently, every time I see the word “vaping” or “vaper” I immediately think of this.

** In case you’re yelling at your screen, “Wait, 7.3% is better than 5.8%, e-cigarettes are kicking nicotine patch’s butt!” I must remind you that it’s not a statistically significant difference.