E-Cigarettes — Under-Regulated And Far From Risk-Free

Electronic or e-cigarettes are hand-held, battery-operated, nicotine delivery systems that are designed to simulate the experience of smoking a cigarette. They are believed to be safer because they do not create the carcinogenic combustion products found in conventional paper cigarettes and help people quit smoking.

Neither of these claims has been clearly proven. And equally or even more concerning is the idea that, though they may help smokers cut back or quit, e-cigarettes serve as a gateway to smoking for adolescents and other non-smokers.

Teens may believe that e-cigarettes are neither harmful nor addictive and they may be attracted by teen-focused marketing and the availability of e-cigarettes in flavors.

The device heats a liquid that contains nicotine, propylene glycol or glycerin, flavorings and other chemicals and creates a vapor that can be inhaled. Even though e-cigarettes avoid many of the toxic aspects of cigarette smoke, they expose the users to nicotine, the addictive substance in tobacco. Newer models of e-cigarettes deliver more nicotine and look less like classic cigarettes than earlier models.

A recent study published in JAMA, The Journal of The American Medical Association, suggests that when high school students start using e-cigarettes, they are more likely to go on to smoke tobacco cigarettes.

It appears, based on the study's findings, that not only are e-cigarettes not as beneficial as we may have initially assumed, better regulation of these electronic nicotine delivery systems (ENDs) is needed.

E-cigarettes can be seen as posing three public health risks:

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• 1) They have the potential to make cigarette use seem more normal and common again, since they are often permitted in locations, such as the work place, where cigarettes have been successfully eliminated;
• 2) They may appeal to non-smokers, including children, because of misconceptions about their safety;
• 3) They may increase the likelihood a person will begin to smoke tobacco and lead to addiction to nicotine.

It was the last two concerns that were the primary focus of the study of e-cigarette use among high school students in California. Would 14-year-olds who used e-cigarettes, but who had not yet smoked combustible tobacco products, such as cigarettes, cigars and hookahs, be more likely than their peers to begin to use these traditional combustible tobacco products over the next year?

The use of combustible cigarette, cigar, and hookah products was significantly higher at both follow up points among those who had used e-cigarettes compared to those who had not.

To find out, researchers surveyed 2530 high school students who had never used combustible tobacco at the start of their ninth grade year, and then six and 12 months later.

Nine percent, 222 of the participants, had used e-cigarettes. Six months later, 31% of this group said they had started to use combustible tobacco products. Only 8% of those students who didn't use e-cigarettes reported the same.

At 12 months, 25% of the e-cigarette users had tried combustible tobacco vs. only 9% of the non e-cigarette students. Thus, the use of combustible cigarette, cigar, and hookah products was significantly higher at both follow up points among those who had used e-cigarettes compared to those who had not.

The authors of the study suggest several explanations for the connection between e-cigarette use and smoking. The risk factors, whether neurological, genetic, psychological, or behavioral, for the use of both electronic and tobacco cigarettes may be the same. Teens may believe that e-cigarettes are neither harmful nor addictive and they may be attracted to teen-focused marketing and the availability of e-cigarettes in flavors.

The teenage years carry an increased vulnerability. They are a time of risk-taking and developing adolescent brains can become sensitized to the pleasurable effects of chemicals like nicotine as well as other drugs.

E-cigarettes, although they are nicotine delivery systems, have been allowed to be marketed without being regulated as either drugs or devices.

So it is a problem that e-cigarettes are easy for teens to get. There are currently few and inconsistent restrictions on their sale to minors
. Additionally, it is possible that exposure to the nicotine in e-cigarettes may provide enough of the desired psychoactive effects that teens seek continued or increased nicotine exposure.

In an editorial accompanying the publication of the study, Nancy Rigotti, a doctor at Massachusetts General Hospital and Harvard Medical School, notes that although they are nicotine delivery systems, e-cigarettes have been allowed to be marketed without being regulated as either drugs or devices.

The FDA has proposed extending its jurisdiction to e-cigarettes — including setting 18 years as a minimum age of sale, requiring health warnings, and creating product standards. But this has not yet been finalized, and Dr. Rigotti calls for timely completion of this regulatory decision.

She also recommends that e-cigarettes be subject to similar use restrictions as combustible tobacco, including banning them from public places and workplaces so that their use will not become ‘normalized,’ and their marketing to children and teens be banned, just as it is with combustible tobacco products.

E-cigarettes have some pubic health benefit. Current smokers may use them to decrease or eliminate their exposure to traditional combustible nicotine products and the resulting cardiovascular disease, lung disease, cancers, and other ailments long associated with smoking. However, this study makes clear that parents, doctors, and public health officials should pay more attention to the negative impact e-cigarettes use can have on teens.

There is an urgent need for public policies to be implemented to address these risks, and in the meantime, parents should educate their children and teens to the idea that e-cigarettes are not as risk-free as they may think.