It looks and glows like a cigarette. Yet it is supposedly healthy and safe and helps you kick the nicotine habit. Is it a contradiction in terms or a wonder cure for smoking?

Due to smoking bans and regulations in most developed countries, the pressure to quit smoking has intensified. But, nicotine addiction continues to be one of hardest addictions to beat. Over the years, smoking cessation aids including nicotine gums, nicotine patches and prescription drugs like Chantix have been widely available but their success rate is nothing to write home about.

Meet the latest and most controversial smoking-cessation method from China: an e-cigarette or e-cig for short. They are also called electronic nicotine delivery systems (ENDS) by the World Health Organization (WHO).

E-cigs are designed to resemble cigarettes in size and appearance but others may be longer or shorter than a standard cigarette and can resemble a pen, a thin lipstick or a USB stick. Others refer to e-cigs as smokeless tobacco (ST) but ST may include chew tobacco and snuff. Other names have been recently coined. Nicotine inhalers. Vapes. Smokeless smokes. E-puffs.

E-cigs are supposed to be cool, healthy, green and risk-free to the user and there is no passive smoke involved. E-cigs have the advantage over gums and patches because they can supposedly help you quit nicotine without giving up ‘smoking’. And manufacturers and distributors claim that e-cigs do not contain tar, carcinogens or other toxic substances found in a normal cigarette.¹

Another key benefit of e-cigs is the absence of health problems attributed to second-hand and third-hand tobacco smoking, health hazards which are the driving force behind the smoking bans. E-cigs also address “suppression of craving and withdrawal that is not entirely attributable to nicotine delivery by successfully emulating the cigarette handling rituals and cues of cigarette smoking".²

And as always, the celebrity factor also counts. Just to name a few famous e-puffers: Britney Spears, Jeremy Piven, Leonardo DiCaprio, Kate Moss, Paris Hilton, Katherine Heigl, Charlie Sheen and Catherine Zeta-Jones and maybe even John Cade.³

E-cigs already generate $100 million in annual sales worldwide. The aggressive marketing techniques of e-cigs as smoking cessation devices have led to its popularity.  U.S. sales exploded in the second half of 2011 when the U.S. FDA lost its case in court trying to ban e-cigs until clinical trials data become available. The Centers for Disease Control and Prevention states that 0.6% of Americans used e-cigs in 2009 and 2.7% used e-cigs in 2010, equivalent to more than 8 million people.^4,5

Swiss researchers looked at the profile of the typical e-cig user or “vaper” and the motivations behind “vaping”. From 3587 respondents, the findings show:⁶

• 70% are former tobacco smokers
• 61% are male
• 97% uses e-cigs with nicotine
• mean age is 41 years old
• an average user draws 120 puffs/day and uses five refills/day
• an average user spends $33 a month for e-cigs
• 96% believes e-cigs helped them to quit smoking
• 92% believes e-cigs helped them reduce their smoking
• 84% believes e-cigs are less toxic than tobacco
• 79% says e-cigs help them deal with tobacco craving
• 57% thinks e-cigs are cheaper than cigarette smoking
• 39% says it helps them handle situations where smoking is prohibited 

So, what’s an e-cigarette?

Electronic nicotine delivery systems (ENDS or electronic cigarettes) look like cigarettes but do not contain or burn tobacco. Instead, they comprise a battery-powered atomiser that produces a vapour for inhalation from cartridges containing humectants (propylene glycol or glycerol), flavours (e.g. tobacco, mint or fruit) and nicotine. Nicotine is delivered through replaceable cartridges that are available in various concentrations (e.g. 16 mg, 11 mg, 6 mg and 0 mg) and can be adjusted to various levels of nicotine as per the needs of the user.

A typical e-cig consists of a cylindrical stainless steel case, a power source (usually a built-in lithium battery), a smart e-chip, a heating device and a cartridge containing a liquid reservoir. It is usually portable and reusable by refilling. The cartridge is located at the mouthpiece and one cartridge may contain nicotine that corresponds to between 15 and 20 cigarettes.

At the other end is a LED light which serves as an operating mode indicator. It glows when the device is in use. The heating device heats up the liquid in the cartridge and vaporizes the solution into an aerosol mist which the user inhales through the mouth. The liquid in e-cigs is usually nicotine with a wide range of flavors from strawberry to cinnamon to chocolate.⁷

Could e-cigarettes be a godsend?

At this juncture, there is very little data to support or contradict the manufacturers’ claims. Health authorities are concerned about how little they know about these novel products and the potential risks involved especially over the long-term.⁸

According to the U.S. FDA “Consumers currently have no way of knowing whether e-cigarettes are safe for their intended use, what types or concentrations of potentially harmful chemicals are found in these products, or how much nicotine they are inhaling when they use these products”.  The FDA also conducted a laboratory analysis in 2009 of two leading e-cig brands and detected the following: carcinogens, including nitrosamines and toxic chemicals such as diethylene glycol, an ingredient used in antifreeze.^9,10

Health Canada is advising “not to purchase or use electronic smoking products, as these products may pose health risks and have not been fully evaluated for safety, quality and efficacy. Nicotine is a highly addictive and toxic substance, and the inhalation of propylene glycol is a known irritant. Although these electronic smoking products may be marketed as a safer alternative to conventional tobacco products and, in some cases, as an aid to quitting smoking, electronic smoking products may pose risks such as nicotine poisoning and addiction".¹¹

Researchers at Stanford write:

“The vapors from ENDS are complex mixtures of chemicals, not pure nicotine. It is unknown whether inhalation of the complex mixture of chemicals found in ENDS vapors is safe. There is no evidence that e-cigarettes are effective treatment for nicotine addiction. ENDS are not approved as smoking cessation devices".¹²

And a recent paper reported a rather unexpected side effect of e-cig use: exogenous lipoid pneumonia which is a chronic inflammatory reaction due to glycerin-based e-cigarettes. Chest CT scans showed damage in the lungs described as “bilateral alveolar consolidation and ground glass opacities, including the “crazy paving” pattern".¹³

Other concerns include:

• Easy access by children and minors to e-cigs
• Limited control on the purity of ingredients, device functionality and quality control
• The ease with which devices can be modified by users for other purposes
• There is a big heterogeneity in the composition and characteristics of the products currently marketed. Although the majority contains nicotine, some don’t. Worldwide, tobacco-specific nitrosamine content varies widely ranging from 4.5 to 516,000 ng/g¹⁴

OK, are e-cigarettes regulated?

Not well. The reasons are nobody is sure or is clear what exactly an e-cig is. Is it a medical device? Is it a smokeless tobacco product or is it a device-drug combination product?

If an e-cig is marketed as just another tobacco product without a purpose to heal, then it can be regulated as any other cigarette or cigarette alternative. However, many argue that an e-cig is not even a tobacco product.

And if an e-cig, as some manufacturers claim, is a stop-smoking aid it would be regulated as a medical device or a device-drug combination product with rigorous testing including clinical trials for safety and efficacy, same as for other pharmaceutical products.

As a result, the status of e-cigs differs from country to country. Singapore and Thailand have completely banned e-cigs. In the UK and many EU countries “the sale and use of electronic cigarettes is legal as long as they are not being marketed as smoking cessation devices.” In the UK  e-cigs are regulated as cigarette alternatives whereas Denmark regulates e-cigs as a medicinal product.¹⁵

In 2010 the FDA tried to ban e-cigs under the premise that they were medical devices. The FDA lost its case when the U.S. Court of Appeals for the D.C. Circuit declared e-cigarettes a tobacco product. Currently the FDA regulates electronic cigarettes under the Family Smoking Prevention and Tobacco Control Act, as well as regulating e-cigs under the Food, Drug and Cosmetic Act similar to other nicotine products such as nicotine gums and patches.^16,17

What does Big Tobacco have to say?

Financial experts believe that e-cig may be the biggest threat to the tobacco industry, even more than the anti-smoking laws. The tobacco giant Philip Morris has already taken steps to counteract this threat. It reportedly acquired the rights to “an aerosol nicotine-delivery system” which is supposedly a better stop-smoking aid than e-cigs because “it delivers nicotine more rapidly to mimic the nicotine 'hit' a cigarette provides smokers.” Furthermore, the company is aiming to market the product as a “medicinal nicotine inhaler”.¹⁸

The second largest cigarette maker, British American Tobacco,  announced that they had bought the rights to the supposedly first “safe cigarette”. The product seems to be a hybrid between e-cigs and traditional cigarette. “It’s going to be much more satisfying than the e cigarette but will have a lower health risk than tobacco”.¹⁹

The Bottom Line

E-cigarettes are different things to different people. 

For nicotine addicts, e-cigs are heaven-sent alternatives to normal cigarettes. It seems that these smoking cessation aids actually work and they also help in circumventing anti-smoking bans.

For anti-smoking activists, e-cigs are a real pain, undoing decades of anti-smoking efforts.

For the regulators, it is a difficult choice between the devil you know and the devil you don’t know. The unknown is always perceived as dangerous.

For the medical professionals, e-cigs seem to be the lesser of the two evils.

For the manufacturers, it’s a way to make big bucks.

For Big Tobacco, if you can’t beat them, better join them.

Whatever e-cig is for you, one thing is for sure: it is here to stay, in whatever regulated or unregulated form it will take. 

A word to the wise…cigarettes used to be considered safe, with doctors and medical experts hailing them as great remedies against stress and lack of concentration. The hazards became only evident decades later. Sadly, the same story may apply to e-cigarettes.

References

1. Weinberg MA, A Profile of Electronic Cigarettes, US Pharm. 2011: 36(7):37-41
2. Rodu B, The Scientific Foundation for Tobacco Harm Reduction, 2006-2011,  Harm Reduction Journal 8:19, July 29, 2011
3. Stein J, Are E-Cigs Cool? Bloomberg BusinessWeek, January 19, 2012
4. Gallegos A, FDA regulation of e-cigarettes rebuffed again, American Medical News, February 14, 2011
5. Rigik E, Lawmakers Targeting Electronic Cigarettes, Convenience Store Decisions, April 12, 2012
6. Etter JF,  Electronic cigarettes: a survey of users,  BMC Public Health 2010, 10:231
7. Etter JF et al, Saliva cotinine levels in users of electronic cigarettes, Eur Respir J. 2011 Nov;38(5):1219-20
8. Electronic Cigarettes Are Unsafe and Pose Health Risks, Study Finds, ScienceDaily, December 5, 2010
9. Electronic Cigarettes, FDA News and Events, October 6, 2011
10. Summary of Results: Laboratory Analysis of Electronic Cigarettes Conducted By FDA, FDA News and Events, July 22, 2009
11. Health Canada advises Canadians not to use electronic cigarettes, Health Canada, March 27, 2009
12. Kuschner WG et al, Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider, Int J Gen Med. 2011 Feb 1;4:115-20
13. McCauley L et al, An unexpected consequence of electronic cigarette use, Chest. 2012 Apr;141(4):1110-3
14. Sohn E, How Safe Are E-Cigarettes? Discovery News, January 26, 2011
15. E-cigarettes, Tobacco Information Scotland, April 2012
16. FDA Cannot Block E-Cigarette Imports: Court, Reuters, Fox News, 8 Dec 2010
17. FDA Fighting for Authority to Regulate Electronic Cigarettes Appeals Court Order Stays Lower Court Ruling in Favor of e-Cigarette Distributors, American Academy of Family Physicians, March 2, 2010
18. Has Marlboro man had his day? Philip Morris to market aerosol that gives a nicotine hit without the need for cigarettes, Daily Mail, 27 May 2011
19. British American Tobacco Buys Rights to Safe Cigarette, Electronic Cigarette News, July 7, 2011