E-cigs: Healthy tobacco alternative? Definitely not

Madeleine BileDuring my public health rotation, I researched the use of electronic cigarettes (“e-cigs”). I soon became aware of the associated dangers. According to the CDC, the extent of e-cig use among teenagers doubled to 10% in 2012. Using effective marketing tactics to lure children and teenagers, this industry reached over a $2 billion market within a few years.  Because young people are not aware of the toxic components of e-cigs, the result has been a 307% increase in nicotine poisonings, 51.1% of which involved young children under the age of five.

E-cigs, also known as vaporizers (“vapes”), were first introduced into the United States in 2007. Although e-cigs can contain less nicotine than conventional cigarettes, they are just as addictive. Inhaled nicotine stimulates the release of dopamine by binding to the nicotine receptor, which contributes to the reinforcing and addicting property. Young people who use both e-cigs and conventional cigarettes smoke more cigarettes and are less likely to quit smoking than those who use cigarettes alone.

Toxins into vapor

E-cigs are battery-operated devices that work by converting liquid nicotine into vapor that smokers inhale. They contain toxic components such as diethylene glycol (found in antifreeze), formaldehyde, and propylene glycol, a main cause of respiratory irritation; prolonged and/or repeated exposure may affect the central nervous system and consequent behavior. When heated and vaporized, propylene glycol can form propylene oxide, a carcinogen. Secondhand smoke, inhaled not only in homes but in public places such as restaurants and parks, increases the risk to others of nicotine-related respiratory disease.

E-cigs are manufactured primarily in China and at present are not regulated by FDA. This is a significant cause for concern. Since 2013, the manufacture of e-cigs has increased, with different varieties containing varying amounts of nicotine and diluents produced under circumstances of very poor quality control.

Unfortunately, most people believe that e-cigs are merely products that simply release harmless water vapor.

Multibillion-dollar industry

Although e-cigs have recently been introduced into the U.S. market, their rapid expansion will soon make this a multibillion-dollar industry. Forceful advertisements market e-cigs on the internet, on television, and in popular magazines as a cheaper and healthier alternative to tobacco products.

Some companies offer free samples of e-cigs over the internet. To attract young people, some e-cig devices play music and some feature liquid nicotine in menthol, fruit, or candy flavors.

These additive flavors in liquid nicotine have enticed children to experiment with e-cigs. This has resulted in the 51% of poisonings from e-cig liquid involving young children under the age five and about 42% involving people 20 years of age and older.

Mislead to succeed?

E-cig marketing tactics play up the theme of smoking cessation. A randomized control trial held in New Zealand looked at smokers who attempted to quit using e-cigs, nicotine patches, or nicotine-free e-cigs. The study showed that the percentage of participants who stopped smoking using e-cigs was slightly higher than for those who used nicotine patches; however, the data were not statistically significant.

FDA has not approved e-cigs as smoking cessation devices, even though they continue to be marketed as such.

E-cigs constitute a major danger for young people, who believe they are safe when in fact they contain nicotine and carcinogens. Over the course of four years, reported cases of liquid nicotine overdose increased more than 300%, with children being the most affected. In 2013, in an effort to protect the underage, 40 state attorneys general signed a letter urging FDA to regulate e-cigs in the same manner as it does conventional cigarettes. 

FDA needs to regulate e-cigs and subject them to the same regulation directed toward conventional cigarettes. The California Board of Pharmacy now officially recommends that e-cigs along with other tobacco products not be sold in pharmacies. 

Pharmacies should be consistent in protecting consumer health and not promote unhealthy life styles. 

Madeleine Bile is a 2014 PharmD graduate, Touro University College of Pharmacy. Contact her at madeleine.bile@tu.edu.

References

Grana R, Benowitz N, Glantz S. E-Cigarettes: A scientific review. Circulation: Journal of the American Heart Association. May 13, 2014; 129(19): 1972–1986. Accessed July 21, 2014.

"E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012." Centers for Disease Control and Prevention, 5 Sept. 2013. Accessed July  20, 2014.

McGill, Natalie. "Research on e-cigarettes examining health effects: Regulations due."  American Public Health Association, Accessed July 1. 2013

Stahl, Stephen. Stahl's Essential Psychopharmacology Print and Online Bundle: Neuroscientific Basis and Practical Applications. 4th ed. Cambridge: Cambridge University Press, 2013.

Press Release: "New CDC study finds dramatic increase in e-cigarette-related calls to poison centers." Centers for Disease Control and Prevention. 3 Apr. 2014. Accessed July 20, 2014.

Fernandez, Elizabeth. "E-Cigarettes: Gateway to Nicotine Addiction for U.S. Teens, Says UCSF Study." University of California, San Francisco. 6 Mar. 2014. Accessed July 20, 2014.

"AGs urgs FDA to regulate sale and advertisement of E-cigarettes."  The National Association of Attorneys General, Sept. 14, 2013. Accessed Aug. 3, 2014. 

Kaplan, Karen . "E-cigarettes to quit smoking? They're as good as nicotine patches." Los Angeles Times, Sept. 9, 2013. Accessed Aug. 8, 2014.