Richard Feldman

The use of electronic cigarettes, commonly known as e-cigarettes, is skyrocketing. While only 50,000 of these little devices were sold in the United States in 2008, sales reached 5 million in 2012.

Manufacturers and other purveyors of e-cigarettes claim they are either safe or abundantly safer than smoking tobacco. Most mainstream public health advocates flatly discourage their use because of potential dangers. Still other public health and medical professionals, some from prominent academic institutions, see the e-cigarette as a legitimate harm-reduction strategy and possible aid to cessation for smokers. So what does one make of this relatively new nicotine product?

E-cigarettes are handheld electronic devices consisting of a rechargeable battery and a cartridge containing nicotine, propylene glycol, glycerin, flavorings and other known and unknown ingredients. When the user inhales air through the device, it activates the battery that heats an atomizer to vaporize the nicotine and other compound,s producing a white aerosol. Since there is no combustion, the user inhales vapor, not smoke, and what is exhaled dissipates quickly and does not produce the offensive lingering, smelly and irritating smoke of combusted tobacco.

Are they harmful? There is a stark lack of good scientific studies; the data just don’t exist to conclusively say one way or another. The few investigations that have been conducted generally demonstrate potential for harm. A Harvard study determined acute pulmonary effects including airway constriction and inflammation that could lead to chronic pulmonary disease. Importantly, long-term cardiopulmonary health effects and cancer risks are unknown.

We do know from federal Food and Drug Administration study and a few other investigations that cartridge samples contain a highly toxic substance called diethylene glycol and a number of carcinogens including nitrosamines. A German study showed that e-cigarette secondhand emissions contained toxins and carcinogens including acetone, isoprene, formaldehyde, acetic acid and acetaldehyde averaging about 20 percent of what cigarettes place in the air. The limited evidence available suggests that there are far fewer identified compounds in e-cigarettes compared to tobacco, and that they generate and deliver fewer toxic substances to the user (other than nicotine) compared to tobacco combustion.

There is also little evidence that e-cigarettes are a convincingly effective tobacco cessation aid. Relatively few smokers use e-cigarettes for complete cessation. They often continue to use them indefinitely, use them in combination with tobacco smoking or revert exclusively to smoking. A recent Lancet journal study demonstrated e-cigarettes to be about as successful for tobacco cessation as conventional pharmaceutical nicotine replacement patches.

E-cigarettes may deplorably lure children into a life of nicotine addiction. They are cheaper than cigarettes and are available in flavors (including cherry, chocolate and bubble gum) that appeal to youth. Use of e-cigarettes among youth has doubled in recent years.

The most immediate issue is the fact that these devices are unregulated. The FDA has signaled its intention to regulate them as tobacco products because their nicotine is derived from tobacco but has yet to assert its authority.

Regulation is needed. Studies have demonstrated that e-cigarettes have poor quality control, design flaws, incomplete and inaccurate labeling, nicotine concentration that differs from what is claimed on the label and no assurance that undisclosed ingredients or unintended contaminants are not present.

Public health professionals fear that the rise in e-cigarette smoking-like behavior may undo decades of efforts to reduce smoking and “renormalize” smoking in our culture. Although e-cigarettes might be a less-toxic alternative for smokers, they are addictive and potentially harmful. From a policy standpoint, their use must be discouraged. From a purely medical perspective, e-cigarettes should be exclusively reserved for those already hopelessly addicted despite all the best tobacco-cessation interventions.

Feldman, M.D., is director of medical education and family medical residency at Franciscan St. Francis Health. Email him at richard.feldman@franciscanalliance.org.