Between January 2000 and December 2007 the United States implemented comprehensive smoke-free laws that prohibited smoking in workplaces, restaurants and bars. The Missouri Clean Indoor Air Law (2000) was Missouri’s response to this movement.1 The law mandated that no public place may have more than 30% of its entire establishment dedicated to smoking and clear signs must be in place to distinguish between smoking and non-smoking sections. Since 2011, Jefferson City, along with other major cities in Missouri, has gone a step further to completely ban smoking in public facilities. Smoking sections are becoming a thing of the past and lit cigarettes can only be spotted on sidewalks, patios, and within private establishments.
Why do we care? According to the Centers for Disease Control and Prevention (CDC), “exposure to second-hand smoke from burning tobacco products causes disease and premature death among non-smokers. There is no risk free level of second-hand smoke and even brief exposure can cause immediate harm.” Since the implementation of smoke-free laws nationwide, there has been a noticeable decrease in the amount of hospital admissions and deaths associated with coronary events, along with respiratory and heart disease.2 The push to eradicate cigarette smoke was an attempt to improve population health, decrease the pervasion of cigarette smoking in the community, and to protect non-smokers from the potentially harmful effects of second-hand smoke. With public smoking becoming more taboo, the need for a more sociably acceptable alternative arose. The answer presented itself on the market in 2007with the electronic cigarette.
Let’s begin with the basics. An electronic cigarette(EC) is a battery-powered device that contains a liquid that is composed of a combination of propylene glycol, vegetable glycerin, flavor concentrates, and varying concentrations of nicotine. During use, the liquid is vaporized, allowing inhalation without combustion or smoke. ECs have been used as a form of smoking cessation and potentially address the chemical (cravings) and behavioral components of tobacco addiction. ECs have been praised as a new and safer alternative to cigarette smoking, but how much do we really know about these new “saviors” that have taken the market by storm? Have they helped decrease the prevalence of cigarette smoking in the community or have the cigarette companies found a new way to appeal to a more diverse and perhaps even younger audience?
A scientific report which monitored nicotine absorption from electronic cigarettes compared to combustible cigarettes (CC) has shown that the use of ECs causes an increase in plasma nicotine levels higher than in people using cigarettes alone.3 New generation electronic cigarette or “vapor” devices are associated with a faster nicotine absorption rate and higher plasma nicotine concentration levels. These rates were higher in experienced vapor users when compared to vapor naïve users. This suggests that nicotine absorption and plasma levels increase after sustained use and adjustment to the electronic delivery device. This faster nicotine delivery may explain the increased effectiveness of electronic cigarettes as a smoking cessation tool, but may potentially increase dependence.
While we have always been concerned with the health risks associated with second-hand-smoke, electronic cigarettes also have a potential to cause harm from nicotine exposure. EC refill bottles and cartridges contain concentrated, toxic amounts of nicotine. This proposes a severe problem for children who may be attracted by the cartridges sweet smells or flavorings. To an unsuspecting youth, the total nicotine content from consumption could prove to be life threatening and since e-cigarettes have no regulations in force, the safety and quality of e-liquids is not guaranteed. Additionally, nicotine from the aerosol or liquid cartridges can remain on surfaces long after exhalation and the aerosol has cleared the room. This residual nicotine left on public surfaces leads to a risk of third-hand exposure through the skin, inhalation and ingestion. Nicotine exposure can lead to adverse effects that may include: irritation, nausea/vomiting, heartburn, dizziness or headache.
Do the benefits of ECs outweigh the risks? Are these devices replacing the other nicotine replacement therapies already on the market for smoking cessation? A 5-year prospective cohort study began in November 2013 with the goal of observing the efficacy and safety of e-cigarettes long term.6 The study is predicted to be completed in 2019; however, preliminary findings presented at a 12 month follow up so far show no significant adverse effects from e cigarette use. Patients enrolled in this study were smokers of ECs only, CCs only or using both interchangeably. After surveying these groups after one year, it was found that nearly a third of all of the patients smoking e-cigarettes only, relapsed to tobacco smoking (n=236) with 10% reverting to using both e-cigarettes and tobacco smoke. For those who were only tobacco smokers at the beginning of the study, nearly 78% of all participants continued this trend, with only 7% quitting tobacco smoke in favor of e-cigarettes (n=491). When looking at the final group who smoked both CCs and ECs, over 50% of participants reverted to tobacco smoking only, 25% continued smoking both forms, and 10% quit tobacco smoking and continued using ECs (n=232). These early findings suggest that e-cigarettes may not be as effective as a tool for smoking cessation or reduction.
The truth of the matter is that electronic cigarettes are targeting a larger consumer base than solely current smokers. According to Dr. Pisinger, in correspondence with BMC medicine, the prevalence of smoking has increased from 24-38% in the past 3 years.7 As ECs become more popular, they have transitioned from being purchased by smokers only, and spread to use by ex-smokers and those who had never smoked at all. ECs come in all shapes and sizes, colors and models that are appealing to all ages. Adolescents between the ages of 12-14 have begun experimenting with ECs and their numbers have doubled in the past couple years.7 The range in flavors available for nicotine vapor come in a wide variety that can appease nearly any taste. The sweet candy-like flavors also seem to appeal to the young in a way cigarettes never could.
I would argue that combustible cigarettes are the most dangerous, legal product on the market and that when comparing to this formidable contender, anything would seem like a safer alternative. The truth is that there are currently no completed clinical trials that show the long term effects of electronic cigarette use. We still do not know what potential health risks these devices present with extended exposure. However, if an EC can convert a lifetime smoker or decrease cigarette consumption, then the health benefits are substantial. I feel, as the World Health Organization (WHO) stated in 2014, “it is an evolving frontier filled with promise and threat for tobacco control.”
UMKC School of Pharmacy in Columbia
Pharm.D. Candidate 2016
- Bureau of Health and Wellness Comprehensive Tobacco Control Program. FAQs About the Missouri State Clean Indoor Air Law. Accessed August 5,2015. http://health.mo.gov/living/wellness/tobacco/smokingandtobacco/pdf/FAQ_CIA.pdf
- Centers for Disease Control and Prevention. Smoke Free Policies Improve Health. Accessed August 5, 2015. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/improve_health/. Accessed August 6, 2015.
- Farsalinos KE, Spyrou A, Stefopoulos C, et al. Nicotine absorption from electronic cigarette use: comparison between experienced consumers (vapers) and naïve users (smokers). Sci Rep. 2015;5:11269.
- Polosa R. Electronic cigarette use and harm reversal: emerging evidence in the lung. BMC Med. 2015;13:54.
- Beard E, Brown J, Mcneill A, Michie S, West R. Has growth in electronic cigarette use by smokers been responsible for the decline in use of licensed nicotine products? Findings from repeated cross-sectional surveys. Thorax. 2015
- Manzoli L, Flacco ME, Fiore M, et al. Electronic Cigarettes Efficacy and Safety at 12 Months: Cohort Study. PLoS ONE. 2015;10(6):e0129443
- Pisinger C. Why public health people are more worried than excited over e-cigarettes. BMC Med. 2014;12:226.