Carlos Cardenas (left), manager of e-cig shop Vapor Invasion in Grantville, and Jack “Papa Jack” Fontes puff on e-cigarettes at the shop. Fontes says he has quit regular cigarettes with the help of e-cigarettes. — K.C. Alfred

Jack “Papa Jack” Fontes just couldn’t kick the habit. He began smoking at age 10 and stuck with it, although he knew of the health dangers.

Today, the 51-year-old said he’s off cigarettes and credits electronic cigarettes for making it possible.

Instead of inhaling cigarette smoke, he inhales — or “vapes” — flavored vapor produced from e-cigarettes. The cloudy vapor looks like smoke, but it’s evaporated at a high temperature, not burned. And it doesn’t stink.

“It’s actually saved my life,” Fontes said. “I’m not getting the 8,000 carcinogens found in a cigarette.”

The El Cajon resident said he suffered a heart attack in 2012 and continued e-cigarette “vaping” with approval from his cardiologist. Fontes still takes nicotine, in the form of vaporized e-cigarette juices that contain varying amounts of the substance.

“My cardiologist said he wants me off nicotine in four years, which is doable,” Fontes said. That means stopping vaping or switching to juices with no nicotine.

For people like Fontes, e-cigarettes provide an option that might help them quit smoking — after nicotine gum, patches and lozenges have failed.

However, that raises a question now being fiercely debated: Have vapers really improved their health or have they exchanged one bad habit for another?

Smoking and e-cigarettes In 2014, about 3.7 percent of American adults used an e-cigarette every day or occasionally. --Of current smokers, 47.6 percent said they have tried e-cigarettes. --Among people who quit smoking within the past year, 55.4 percent said they had tried e-cigarettes. --Of those who quit smoking more than a year ago, 8.9 percent said they had tried e-cigarettes. --Among adults who have never smoked cigarettes, 3.2 percent said they have tried e-cigarettes. --Among people 18-24 who have never smoked, 9.7 percent said they have tried an e-cigarette. --For those 45 or older who have never smoked, up to 1 percent said they have tried an e-cigarette. Sources: U.S. Centers for Disease Control and Prevention

Smoking cessation brings undisputed health benefits. In contrast, scientists can only make an educated guess about the effects of switching to e-cigarettes. Researchers said it’s their impression that vaping is much safer than smoking, which is backed by a few studies. But many more years will be needed to draw firm conclusions.

Those nuances are often lost in public health campaigns against vaping, which depict it as a “Big Tobacco” conspiracy to ensure another generation of nicotine addicts.

E-cigarette supporters said theirs is a grassroots movement, representing a practical way out from the dangers of smoking when other methods have failed. And, they’ll add, it’s a pleasure in its own right.

Risk assessment

Nicotine itself brings health hazards. It constricts blood vessels and may interfere with fetal brain development. There’s no clear evidence whether it increases the risk of cancer or heart disease.

On the positive side, some studies hint that nicotine may play a neuroprotective role, reducing the risk of Parkinson’s disease, improving cognitive function and even protecting against Alzheimer’s disease.

But the main concern with cigarette smoking is not nicotine. It’s the thousands of toxic chemicals carried in smoke from burning tobacco. These include lung-fouling tar and the carcinogens benzene, cadmium and nicotine-derived nitrosamine ketone.

E-cigarettes contain components such as refillable tanks and rechargeable batteries. — K.C. Alfred

At least 85 percent of lung cancer deaths occur in smokers. An estimated 158,040 Americans are estimated to have died from lung cancer in 2015, according to the American Lung Association.

Compared with those who have never smoked, male smokers are 23 times more likely to develop lung cancer, and women 13 times more likely, the association said.

Scientists have a century of studies on cigarettes to back up such conclusions.

On the other hand, e-cigarettes became popular scarcely a decade ago, said researcher Dr. Laura Crotty Alexander of the VA San Diego Healthcare System and UC San Diego, two major centers of e-cigarette research. So any long-term hazards of vaping simply haven’t had time to show up.

“I wish I had an answer based on tons of high-quality data, but we don’t have that yet,” Crotty Alexander said. “As far as I can tell, based on the very little data we have, cigarettes are more dangerous.”

UCSD/VA San Diego researcher Laura Crotty Alexander. — Amanda Dean Photography

A specialist in lung diseases, Crotty Alexander guessed that cigarettes could be more than 80 percent more dangerous than vaping. She reasons that cigarette smoke is known to contain extremely dangerous chemicals absent in e-cigarettes. So delivering nicotine through electronic cigarettes could deliver the buzz of smoking without its most harmful health effects.

Ross Corriden, a researcher at UC San Diego’s pharmacology department who works with Crotty Alexander, said he’s concerned that vapers may be underestimating potential risks.

“I think the problem is e-cigarettes are being touted as completely safe, you’re only getting purified nicotine,” Corriden said. “I think it would be hard to argue that conventional cigarettes aren’t more dangerous than e-cigarettes, (but) there certainly are risks associated with e-cigarettes that haven’t been really investigated.”

On balance, displacing cigarette smoking with e-cigarette vaping is better for health, he said. But for those who don’t smoke, vaping imposes a new health risk.

UCSD researcher Ross Corriden holds a syringe filled with e-cigarette vapor. The vapor is infused into a liquid in the syringe containing cell nutrients. Human cells are grown in this liquid to assess how cells react when exposed to chemicals in the vapor. — K.C. Alfred

Still another colleague, Dr. Jessica Wang-Rodriguez, said in December that e-cigarettes are as bad as smoking, based on the kinds of damage seen in a study she took part in.

Published in December, the study showed DNA damage to cells in culture from e-cigarette vapor, a possible cause of cancer. However, she added a caution that the cells tested were altered to grow in the lab, and the study didn’t try to replicate the actual dose vapers would get.

Aside from the opinions of scientists, research supports the view of vapers such as “Papa Jack” Fontes that giving up smoking for e-cigarettes benefits health to a degree. A study last year by Public Health England endorsed e-cigarettes for smokers. It concluded that e-cigarette use carried just 5 percent of the risk of smoking.

Even that calculation seems too high for tobacco and e-cigarette researcher Dr. Michael Siegel of Boston University, who recommends e-cigarette use as an alternative to smoking. Siegel said opposition to e-cigarettes is based more on an an ideology that rejects anything resembling smoking than the empirical evidence.

As with Crotty Alexander, Siegel said there isn’t enough data to make a formal risk estimate.

For more on vaping as a smoking alternative: Calif. Dept. of Public Health (anti-vaping) stillblowingsmoke.org Public Health England's report (pro-vaping) j.mp/englandvapingsafer Tobacco Analysis (pro-vaping) https://tobaccoanalysis.blogspot.com/ Chicago Department of Public Health (anti-vaping) j.mp/chicagonovape American Vaping Association (pro-vaping) https://vaping.info/

“All that I can say based on the evidence that’s out there is that it’s much, much safer — orders of magnitude safer,” Siegel said. “But I can’t put a number on it. My impression is that 5 percent (of smoking risk) is way too high. That would be about 20,000 deaths a year, and I don’t think that’s feasible.”

These varying estimates underscore the uncomfortable point that so far, medical science cannot provide definitive advice. The best it can say is that vaping is almost certainly far less dangerous than smoking.

If true, people who switch from smoking to vaping are making a positive change. But for those who don’t smoke, taking up vaping probably adds some level of health risk.

Media hype

Crotty Alexander was also an author on the controversial VA-led study published in December. The analysis found that cigarette smoke was far more toxic to cell cultures than e-cigarette vapors, but that those vapors also caused cell damage. This was a warning that e-cigarettes are not benign, she said.

But as with Wang-Rodgriguez, she said there was no proof that the same damage took place in the bodies of actual vapers.

Published in the journal Oral Oncology, the study gained worldwide coverage based on Wang-Rodriguez’s opinion about the risk level of e-cigarettes, which was included in a news release but not the study itself. Many journalists failed to note the difference. Their stories inaccurately said the study had found that vaping and smoking were equally dangerous.

The vaping community took to Twitter to denounce the articles. To correct the erroneous reports, VA San Diego Healthcare System updated its news release with a clarification.

“Contrary to what was stated or implied in much of the news coverage resulting from this news release, the lab experiments did not find that e-cigarette vapor was as harmful to cells as cigarette smoke. In fact, one phase of the experiments, not addressed in the news release, found that cigarette smoke did in fact kill cells at a much faster rate,” the clarification stated.

“However, because similar cell-damage mechanisms were observed as the result of both e-vapor and regular cigarette smoke, Dr. Wang-Rodriguez asserts, based on the evidence from the study, that e-cigarettes are not necessarily a healthier alternative to smoking regular cigarettes. As stated in the journal paper and the news release, further research is needed to better understand the actual long-term health effects of e-cigarettes in humans.”

What’s in an e-cigarette?

Chinese pharmacist Hon Lik is credited with inventing the e-cigarette. He came up with the device in 2003 with the goal of helping smokers to quit.

All electronic cigarettes vaporize liquids that carry an assortment of flavors, some with varying amounts of nicotine and some without any nicotine at all. These liquids are vaporized in the device and inhaled into the lungs, where nicotine (in applicable flavors) enters the bloodstream and then travels to the brain. The liquids’ chief component is propylene glycol, which is on the U.S. Food and Drug Administration’s “generally recognized as safe” list of food additives.

The flavors themselves are often whimsical. While cigarette smokers have just one choice — menthol — e-cigarette juices contain flavors such as banana split shake, OMG (orange, mango, grape), piña colada, strawberry cheesecake and hundreds more.

E-cigarette opponents said these candy-like flavors indicate that the e-cigarette industry is targeting children. Supporters said these flavors are sold because they’re popular with adult users.

E-cigarette industry Value of vaping industry: estimated $1.5 billion in United States. Number of e-cigarette users in the United States: 7 million to 10 million E-cigarette stores in California: about 2,700. People employed in vaping industry (including manufacturing, warehousing, shipping and delivery): roughly 250,000. Shane Simpson, co-president of the Southern California branch of the Smoke-Free Alternatives Trade Association and owner of the C3 Vapors shop in Costa Mesa

The important parts of an e-cigarette are the reservoir that contains the liquid, the atomizer that heats the liquid until it vaporizes, the battery that powers the atomizer, the regulator that controls current and voltage, and the mouthpiece through which the vapor is drawn.

At the low end are disposable e-cigarettes, widely available at liquor and convenience stores, bars and supermarkets. They cost about $10 or less, and most closely emulate the smoking experience. They typically last for several hundred puffs.

Mid-level devices contain refillable tanks and rechargeable batteries, starting from about $20 on up. These give users the convenience of switching flavors and nicotine levels just by filling with a different juice.

And on the high end, for about $100 or more, vapers can custom-build their own devices, adding bigger tanks, more powerful batteries and controls to vary the voltage and wattage sent to the atomizers. By adjusting these components, e-cigarette users can increase the amount or rate of vapor produced.

Local research

Crotty Alexander and others from VA San Diego and UC San Diego are attempting to get an approximation of e-cigarette risk by growing cells in cultures exposed to e-cigarette vapors, looking for signs of damage, and understanding the mechanisms causing the damage.

As drug companies know only too well, cell cultures are known to be an imperfect proxy for people or animals. Cells grow differently in cultures than in the body, which performs functions such as eliminating toxins not found in cell cultures.

One of the most common experiences in the drug industry is that a drug that works wells in cell cultures doesn’t work or produces some unacceptable side effect in animals. And even drugs that work in animals often don’t work in humans.

That said, there’s certainly enough grounds for concern to warrant further study of the effects of e-cigarette use.

In 2014, VA San Diego and UC San Diego investigators led by Crotty Alexander found that in lab cultures, e-cigarette vapor makes the superbug MRSA more virulent. The vapor stresses the bacteria by making the environment very alkaline. So the MRSA bacteria turn on their defenses, which also reduces the effect of antimicrobial substances produced by cells lining the surface of the nose and pharynx.

E-cigarette smoke may interfere with the immune system, said Corriden, Crotty Alexander’s colleague at UC San Diego. He is collaborating with her in exploring the effects of e-cigarette smoke on white blood cells called neutrophils. These are among the first immune-system components to confront invading pathogens, and they’re vital in preventing infections from getting established. Neutrophils are a major component of pus.

“Based on the work we have done so far, and based on the work of other labs, there definitely seem to be some effects on the white blood cells,” Corriden said. “Some of the responses we’ve found have been quite dramatic, to even the minimal list of ingredients that are found in all e-cigarettes. ... Neutrophils are inhibited from detecting and attacking bacteria.”

Risk can also vary with the flavorings. The flavoring Cinnamon Ceylon was the most damaging to cell cultures of 36 flavors tested, according to a March 2014 study led by Prue Talbot of UC Riverside.

Public policy

While the medical evidence so far indicates that e-cigarettes appear to be safer than smoking, some public-health campaigns against smoking have equated the two. That’s the message of the California Tobacco Control Program, run by the California Department of Public Health.

Funded through cigarette taxes, the program was established to reduce smoking. It has lately attacked e-cigarette use with dire warnings of dangers gleaned from studies, but not including the cautions that scientists such as Crotty Alexander and Siegel have given about the early stage of research.

The Legislature has also intervened, passing measures to regulate e-cigarettes along with smoking as tobacco products, raising the legal age to use of both from 18 to 21. The law has yet to be signed by Gov. Jerry Brown, who hasn’t indicated what he will do.

Information posted on the website stillblowingsmoke.org warns that e-cigarette vapor contains toxic chemicals and produces undesired effects in cell cultures, including the Crotty Alexander-led study about as suppressing immune activity and increasing the virulence of the “superbug” MRSA.

Some of the warnings of toxicity look less dangerous in context. The site links to an NBC article about a January 2015 study in the New England Journal of Medicine that concluded e-cigarettes can generate high levels of formaldehyde, a known carcinogen in high doses.

The article said vaping 3 milligrams of e-cigarette liquid vaporized at a high voltage can produce 14 milligrams of formaldehyde.

Formaldehyde is a natural and essential chemical in the human body, according to the U.S. Food and Drug Administration. It can be toxic if taken in large enough doses.

However, the NBC article doesn’t compare the amount normally present in the body with the amount added from e-cigarettes, or from consuming common foods such as fruits, vegetables and meats. Without that information, it is impossible to know whether the added dose raises the level of formaldehyde to a dangerous level.

In addition, a study published in the August 2015 issue of the journal Addiction found that high levels of formaldehyde and related chemicals are generated only when the liquids are overheated. This produces an unpleasant taste called “dry puff” that vapers avoid.

So a realistic simulation would examine the amount of formaldehyde produced at commonly used voltages, the study concluded.