are electronic cigarettes a public good or health hazard

5/21/2018 Are Electronic Cigarettes a Public Good or Health Hazard

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Are Electronic Cigaret tes a Publ ic Good or Health Hazard?

A new case study byJohnQuelchcharts the growing popularity of electronic cigarettesand how tobacco companies and regulators are responding.

by Michael BlandingWhen electronic cigarettes first appeared a little over a decade ago, they were hailed bymany as a godsend: a tool to help smokers quit while mitigating the most harmfuleffects of tobacco. "The [e-cigarette] market is producing, at no cost to the taxpayer, anemerging triumph of public health," one health advocate said.Consisting of a small barrel-shaped design that mimics an actual cigarette, the devicesvaporize a liquid nicotine solution, which is then inhaled without the tar and carcinogensfound in smoke. Powered by a battery and controlled with a microchip, users can adjustthe amount of nicotine they inhale, gradually weaning themselves off their addiction ifthey choose.

THE VALUE PROPOSITION OF E-CIGARETTES IS CLEAR

"The value proposition of e-cigarettes is clear," saysJohn A. Quelch,Charles EdwardWilson Professor of Business Administration at Harvard Business School. "They providethe dubious pleasure of nicotine without all the cancer-inducing toxins associated withtobacco."Very quickly, however, enthusiasm faded, when some public health advocates beganworrying that the cure was worse than the disease. And this week the Food and Drug

Administration is proposing thefirst federal oversightof the product.

The very fact users could control the amount of nicotine they ingested led to worry thate-cigarettes would cause smokers to take in more nicotine, rather than less. Even more

worrisome, e-cigarettes could provide a gateway for young people to start smokingtobacco cigarettes, or even lure ex-smokers back to the habit.This has created a dilemma for health regulators, says Quelch, interviewed before theFDA's action. Do they regulate e-cigarettes in order to decrease the number of newsmokers who may pick up the habit, or do they apply a light hand in order to increasethe number of existing smokers who will quit."Put crudely," says Quelch, "how many nicotine addicts is it worth the risk of creating tohave one tobacco smoker quit?"

Electronic cigarettes are powered by a battery and microprocessor.Photo: iStockPhoto

That is one of the many questions Quelch explores in the HBS case , E-Cigarettes:

Marketing Versus Public Health,written with HBS Research Associate Margaret L.

Rodriguez. It examines the consequences of the products as they have become morepopularand as the big tobacco companies have gotten in on the game. Quelch, whoholds a joint appointment at HBS and Harvard School of Public Health, wrote the casefor a new course debuting next year called "Consumers, Corporations, and PublicHealth," which will enroll both MBA and MPH students to consider the intersections ofbusiness and health.
http://www.hbs.edu/faculty/Pages/profile.aspx?facId=6684&click=bestbethttp://www.hbs.edu/faculty/Pages/profile.aspx?facId=6684&click=bestbethttp://www.hbs.edu/faculty/Pages/profile.aspx?facId=6684&click=bestbethttp://www.nytimes.com/2014/04/24/health/fda-will-propose-new-regulations-for-e-cigarettes.html?hp&_r=0http://www.nytimes.com/2014/04/24/health/fda-will-propose-new-regulations-for-e-cigarettes.html?hp&_r=0http://www.nytimes.com/2014/04/24/health/fda-will-propose-new-regulations-for-e-cigarettes.html?hp&_r=0http://hbr.org/product/e-cigarettes-marketing-versus-public-health/an/514059-PDF-ENGhttp://hbr.org/product/e-cigarettes-marketing-versus-public-health/an/514059-PDF-ENGhttp://hbr.org/product/e-cigarettes-marketing-versus-public-health/an/514059-PDF-ENGhttp://hbr.org/product/e-cigarettes-marketing-versus-public-health/an/514059-PDF-ENGhttp://hbr.org/product/e-cigarettes-marketing-versus-public-health/an/514059-PDF-ENGhttp://hbr.org/product/e-cigarettes-marketing-versus-public-health/an/514059-PDF-ENGhttp://www.nytimes.com/2014/04/24/health/fda-will-propose-new-regulations-for-e-cigarettes.html?hp&_r=0http://www.hbs.edu/faculty/Pages/profile.aspx?facId=6684&click=bestbet


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"One of the themes in the course is the tension that exists, quite understandably,between regulators and commercial interests," says Quelch. "Most people are used tohearing about that in the context of financial regulation, but similar issues apply in othersectors of the economy including health care."In the case of electronic cigarettes, existing evidence indicates that they have led to a

net decrease in smoking. Of the 43.8 million smokers in the United States in 2012, 3.5million converted to e-cigarettes; during the same period only 1.3 million electroniccigarette smokers converted to tobacco. That means a net decrease of cigarettesmokers of 2.2 million, or 5 percent.

At the same time, 2.8 million nonsmokers converted to electronic smokes. But even thatdoesn't tell the whole story, says Quelch, since it leaves out the number of smokers whowould have taken up tobacco if e-cigarettes didn't exist, as well as the number ofsmokers who would have quit cold turkey without the availability of electronic products."To really determine the public health impact of e-cigarettes requires a lot ofsophisticated market research and analysis," says Quelch.

A SMOKING MARKET

Uncertainty over health data hasn't hurt the product's popularity. In 2013, electroniccigarettes tripled in sales in the US to approximately $3 billion. (The overall tobaccoretail market in the US is valued at around $100 billion.) Almost 10 percent of highschool students have tried them, according to the Centers for Disease Control, and agrowing percentage of middle school students are joining the list. In 2012, GoldmanSachs declared electronic cigarettes one of the top 10 disruptive technologies to watch. Like most disruptive technologies, electronic cigarettes were developed by smallentrepreneurs with brand names like Logic e Cigarettes (founded 2010), Blu (2009), andNJOY (2006). By 2013, according to the case study, the e-cigarette category featured

more than 200 brands and their growth was threatening sales of tobacco products. "If I am a tobacco manufacturer seeing my sales cannibalized by e-cigarettes, I havetwo choices: develop my own e-cigarette brand or buy an e-cigarette company,"says Quelch.Number three tobacco company Lorillard was the first to blink, buying up Blu in 2012 for$135 million and aggressively pushing them at convenience store counters. "Distributionof Blu immediately increased by a factor of three," says Quelch. Other topmanufacturers followed suit, acquiring their own brands and using their shelf-spaceclout to increase visibility of the alternative products.

CIGARETTE COMPANIES WILL MANAGE THE MARKETING OF E-CIGARETTE

BRANDS TO MAXIMIZE PROFITABILITY FOR THEIR SHAREHOLDERSThe growing sales of electronic cigarettes also caught the attention of regulators. Theproducts had been completely unregulatedthey could be advertised on TV and sold tobuyers of any age on the Internet. But once the major tobacco brands began acquiringe-cigarette makers and displaying those products alongside their mainstay cigarettes,policymakers took particular notice.Public health advocates and parents alike worried about the variety of flavors, includingcotton candy that might make "vapes" attractive to children. Some states and cities


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responded with restrictions on sales and advertising, and, in April, the Financial Timesreported that the World Health Organization will call for e-cigarettes to be regulated justlike tobacco cigarettes. The US Food and Drug Administration, under mountingpressure to act, offered its own regulatory plan on April 24. Ironically, if regulation does go forward, it might help the major tobacco companies by

limiting the marketing playbook of the competitors that were cannibalizing sales of theirproducts.The top tobacco competitors know how to deal with regulators, says Quelch, "but withall those entrepreneurs coming out with flavors and advertising, they would no longer beable to get traction in their business."

TOBACCO COMPANIES TAKE CONTROL

Quelch predicts the big three tobacco companiesAltria, R.J. Reynolds, and Lorillardwill gain control of the e-cigarette market and then under market their electronicproducts in order to retain market share for their more profitable tobacco cigarettes.

"Cigarette companies will manage the marketing of e-cigarette brands to maximizeprofitability for their shareholders," says Quelch. "Meaning they'll be able to manipulateprices in order to control the speed with which tobacco users migrate to e-cigarettebrands."That means that electronic cigarettes, which are now significantly cheaper on a smoke-per-smoke basis than heavily taxed tobacco competitors, will probably start climbing inprice and eventually become equal to tobacco brands. That could create an even biggerwindfall for tobacco producers. Even if electronic cigs are regulated like regularcigarettes, they probably won't be taxed like regular cigarettes, since the tax is ontobacco, not nicotine (and doesn't apply, for example, to nicotine gum or nicotinepatches)and any new taxes are a nonstarter these days in Congress.

By pricing electronic and tobacco cigarettes to sell similarly at retail, the tobaccocompanies could reap enormous profits, concludes Quelch, at the same time givingthem cover against criticism by allowing them to point to "healthier alternatives" in theirproduct portfolios.When entrepreneurs first created e-cigarettes and marketed them as a way to quitsmoking, they probably didn't intend to eventually pad the bottom line of mainstream bigtobacco companies. But playing out the scenario to the end, that is exactly what mayhappenand all in the absence of any definitive data showing whether e-cigarettes aremore or less harmful to public health than tobacco smokes. By pointing out such dichotomies and unintended consequences, Quelch hopes he canmotivate MBA students to think more deeply about the public health impacts of business

decisions, as well as getting MPH students to think about the business forces thatshape public health. Only then will decisions be made that properly balance the greatestgood of the public with the ability for entrepreneurs to turn a profit

REFERENCE:http://hbswk.hbs.edu/item/7449.html
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Research on e-c igaret tes examinin g heal th ef fects :

Regulat ions dueNatalie McGil l

With the look and feel of real cigarettes, electronic cigarettes are experiencing a boomin popularity. But as the products popularity rises, so do the unknowns about its

potential impact on public health.

As scientific studies on e-cigarettes attempt to catch up with their popularity, it remainsto be seen if the products will be a boon to smoking cessation or a setback toward thegoal of cutting out nicotine for good.

E-cigarettes are battery-powered devices that convert nicotine into vapor. The productsare sold over the counter and are not subject to the same regulation as actualcigarettes. A 2011 survey showed that about 21 percent of smokers had used e-cigarettes at least once up from about 10 percent of smokers who took the sameWeb survey in 2010, according to a Center for Disease Control and Prevention study

published online in February in Nicotine & Tobacco Research. About 7 percent ofsmokers who received the same survey in 2010 via postal mail also said they had triede-cigarettes at least once.The Food and Drug Administration announced in 2011 that the agency plans to proposeregulating e-cigarettes as a tobacco product, according to Jennifer Haliski, a publicaffairs officer for FDAs Center for Tobacco Products. Any product containing nicotinefrom tobacco, unless marketed for therapeutic purposes, is considered a tobaccoproduct, according to the 2009 court case,Sottera Inc. v. Food and Drug Administration.

However, concrete regulations on e-cigarettes have yet to be issued, as the science isstill catching up.

Further research is needed to assess the potential public health benefits and risks ofelectronic cigarettes and other novel tobacco products, Haliski said.

Getting regular smokers to quit is a potential public health benefit of e-cigarettes, saidMaciej Goniewicz, PhD, an assistant professor of oncology at the Roswell Park CancerInstitutes Division of Cancer Prevention and Population Sciences.

Goniewicz said that so far he sees e-cigarettes being mostly used by regular smokers rather than first-time smokers as an alternative to smoking cigarettes, offeringanother chance to quit after a relapse. Goniewicz is one of five authors of a Nicotine &Tobacco Research study published online in April 2012 that compared nicotine and

organic compound vapors of 16 e-cigarette brands available in U.S., United Kingdomand Polish markets. The study found 300 puffs of e-cigarettes labeled as having highnicotine levels delivered 0.5 to 15.4 milligrams of nicotine considered negligiblecompared to toxins in regular cigarettes.

However, Goniewicz said there is limited data about whether what is exhaled from e-cigarettes contributes to exposure for people besides the user.
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We know theres almost nothing there compared to cigarette smoke, Goniewicztold The Nations Health. But we dont know whats going on after a very longexposure. We need to wait for the studies.

Regular use of nicotine, which is found in tobacco, is not without its own health effects.An addictive substance, nicotine use can lead to increased blood pressure and heartrate as well as nausea, sweating and diarrhea, according to the National Institutes ofHealth. E-cigarettes are not the only product to deliver nicotine to users. A variety ofproducts are used to provide nicotine to users as a tool for smoking cessation, but suchtools are regulated by FDA.

FDA-approved over-the-counter cessation products include nicotine replacementchewing gum, lozenges and skin patches. In addition, FDA regulates prescription drugsthat block nicotines effects on a smokers brain.

Tim McAfee, MD, MPH, director of CDCs Office on Smoking and Health and an APHAmember, said it is reasonably certain that if someone who smoked a pack a day

switched completely to e-cigarettes it could represent a benefit to health, but there arestill many caveats and buts around that.

One concern is the use of e-cigarettes in businesses or restaurants to skirt clean airordinances or indoor smoking bans, McAfee said. Use of e-cigarettes in places withestablished indoor smoking laws could be a step backward for public health when itcomes to air quality, as well as a negative for someone who may have otherwise quitnicotine, he said.

Someone should not have to go in a restaurant and wonder whats coming out of aplastic device that is completely unregulated, McAfee said. And we know that nicotine

comes out, which is not fair to expose people to in a public space, since nicotine is apsychoactive substance.

In Washington, D.C., two members of the Council of the District of Columbia are notwaiting for more studies before proposing regulations.

An exhibitor demonstrates an electronic cigarette at a consumer electronics show in LasVegas in 2012. While such products are growing in popularity, their health risks areunclear.

Photo by Bruce Bennett, courtesy Getty Images

Council membersYvette Alexander and David Grosso introduced legislation April 9 toclassify e-cigarettes as regular cigarettes that are already prohibited in indoor areas inthe city.

Alexander, who chairs the Councils Committee on Health, said her council staff told herthat they had seen people using e-cigarettes inside city bars and restaurants. On asubsequent trip to a convenience store to find one, a man told Alexander he hadsearched for the device in a quest to quit smoking, she said.


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These e-cigarettes are marketed in one way in that if you want to smoke you cansmoke indoors, Alexander toldThe Nations Health. You can beat the ban by smokingthese e-cigarettes, thats one marketing tool.

Alexander noted that e-cigarettes are also touted as an alternative for people trying toquit smoking. However, it is uncertain if they are less addictive than traditionalcigarettes.

Everyone is up in arms that Im trying to ban the e-cigarettes, Alexander said. Im justtrying to ban them as the same way tobacco products are banned indoors. If you wantto purchase them and smoke them in places where you can smoke tobacco products,thats fine. But we just want to maintain the ban on tobacco products for indoor use.

Another potential public health concern is how the product is marketed toward teensand young adults. According to CDC, teens who use smokeless tobacco are more likelythan nonusers to smoke cigarettes, which is a trend CDCs McAfee said he does notwant to see replicated with e-cigarettes.

Jennifer Pearson, PhD, MPH, a research investigator at the Schroeder Institute forTobacco Research and Policy Studies at the American Legacy Foundation, said that e-cigarettes are a novelty product for young adults, along the lines of hookah. Pearson isa co-author of a study on e-cigarette awareness published in the September issue of

APHAsAmerican Journal of Public Health.

Its (seen as) something fun, different you can do when you go out and something youcan do in the clubs because youre not going to get kicked out, Pearson said.

E-cigarettes continue to evolve, with new models in the absence of federal regulation.Goniewicz said that rather than limit access to the product, he would prefer thatregulations ensure quality and safety and prevent advertising to children.

My point of view is that we still have cigarettes, and this is the main problem,Goniewicz said.

REFERENCE

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Electron ic c ig aret tes: Help o r hazard?

Harvey B. Simon, M.D., Editor, Harvard Health

Kicking the cigarette habit is one of the best things that smokers can do for themselves.

Nicotine replacement products, prescription medications, and counseling can all help.

What about the newest tobacco substitute, the electronic cigarette? Despite the appeal

of so-called e-cigarettes, we dont know enough about their safety or effectiveness togive them the green light

.Electronic cigarettes come in a variety of shapes. Some look like cigarettes, pipes, or

cigars, while others are disguised as pens or other more socially acceptable items.

Whatever their shape, they all are built around a battery-operated heating element, a

replaceable cartridge that contains nicotine and other chemicals, and an atomizer that

converts the chemicals into an inhalable vapor

.A study published this spring in theAmerican Jo urnal of Prevent ive Medic ine

concluded that electronic cigarettes mayhelp smokers quit. Whether they are a safe

way to quit is another questionpreliminary studies from the FDA, New Zealand, and

Greece raise some concerns.

There are three reasons to worry about electronic cigarettes.

First, the dose of nicotine delivered with each puff may vary substantially. An FDA

analysis recorded nicotine doses between 26.8 and 43.2 micrograms per puff. It also

detected nicotine in products labeled as nicotine free.

Second, electronic cigarettes deliver an array of other chemicals, including diethylene

glycol (a highly toxic substance), various nitrosamines (powerful carcinogens found intobacco), and at least four other chemicals suspected of being harmful to humans. To

be sure, the dose of these compounds is generally smaller than found in real cigarette

smoke. But it isnt zero.
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Third, by simulating the cigarette experience, electronic cigarettes might reactivate the

habit in ex-smokers. They could also be a gateway into tobacco abuse for young people

who are not yet hooked.

REFERENCE

http://www.health.harvard.edu/blog/electronic-cigarettes-help-or-hazard-201109223395
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E-c igaret te vapor con tains nico t ine, no t other tox ins

BY SHEREEN JEGTVIG

(Reuters Health) - People standing near someone using an e-cigarette will be exposed

to nicotine, but not to other chemicals found intobaccocigarette smoke, according to a

new study.

E-cigarettes, or electronic cigarettes, create a nicotine-rich vapor that can be inhaled, or

'vaped.'

Researchers and regulators have questioned whether e-cigarettes are a smoking

cessation aid or may lure more young people toward smoking, as well as what effects

they have on health.

"There is ongoing public debate whether e-cigarettes should be allowed or prohibited in

public spaces," study co-author Maciej Goniewicz told Reuters Health in an email.

Goniewicz is a cancer researcher in the Department of Health Behavior at the Roswell

Park Cancer Institute in Buffalo, New York.

"E-cigarettes contain variable amounts of nicotine and some traces of toxicants. But

very little is known to what extent non-users can be exposed to nicotine and other

chemicals in situations when they are present in the same room with users of e-cigarettes," Goniewicz said.

He and his colleagues conducted two studies of secondhand exposure to e-cigarette

vapors in a laboratory. Their results were published in Nicotine andTobaccoResearch.

In the first study, the researchers used an electronic smoking machine to generate

vapor in an enclosed space. They measured the amount of nicotine as well as carbon

monoxide and other potentially harmful gases and particles in the chamber.

The second study included five men who regularly smoked both tobacco cigarettes and

e-cigarettes. Each man entered a room and smoked his usual brand of e-cigarette for

two five-minute intervals over an hour while the researchers measured air quality. The

room was cleaned and ventilated and the experiment was repeated with tobacco

cigarettes.
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The researchers measured nicotine levels of 2.5 micrograms percubicmeter of air in

the first study. Nicotine levels from e-cigarettes in the second study were slightly higher

at about 3.3 micrograms per cubic meter. But tobacco cigarette smoking resulted in

nicotine levels ten times higher at almost 32 micrograms per cubic meter.

"The exposure to nicotine is lower when compared to exposure from tobacco smoke.

And we also know that nicotine is relatively safer when compared to other dangerous

toxicants in tobacco smoke," Goniewicz said.

E-cigarettes also produced some particulate matter, but regular cigarettes produced

about seven times more. E-cigarettes didn't change the amount of carbon monoxide or

other gases in the air.

"What we found is that non-users of e-cigarettes might be exposed to nicotine but not tomany toxicants when they are in close proximity to e-cigarette users," said Goniewicz.

"It is currently very hard to predict what would be the health impact of such exposure,"

he added.

He said more research is needed to find out how the current findings correspond to

"real-life" situations, when many people might be using e-cigarettes in a room with

restricted ventilation.

"This is an interesting piece and points in the direction that a number of other studies

are pointing, though it begins to expand the evidence on the potential effects to others,"

Amy Fairchild told Reuters Health in an email.

Fairchild was not involved in the new research, but has studied how e-cigarette use

might impact views on regular cigarettes at the Columbia University Mailman School of

Public Health in New York.

She said the study suggests e-cigarettes are far safer, both in terms of toxins and

nicotine, than tobacco cigarettes when it comes to the health effects on bystanders -

although more research is needed to know for sure.

"In locales considering extending smoking bans to e-cigarettes, I think that these data

weaken the case for more sweeping bans," Fairchild said. "And so this begins to answer
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the question about why e-cigarettes are considered better: they reduce risks to both the

user and to the bystander when compared to tobacco cigarettes."

Fairfield said the concern about vaping ultimately revolves around whether e-cigarettes

are going to change broader patterns of smoking at the population level.

"There are potential harms, including promoting continued smoking of cigarettes and

renormalizing cigarette smoking behaviors," Goniewicz said. "Regulatory agencies

around the world will need to make a number of regulatory decisions about product

safety that could have major effects on public health."

Goniewicz has received funding from a drug company that makes medications to aid

smoking cessation. Another study author has received funds from an e-cigarette

manufacturer.

REFERENCEhttp://www.reuters.com/article/2014/01/03/us-e-cigarette-idUSBREA020K820140103
http://www.reuters.com/article/2014/01/03/us-e-cigarette-idUSBREA020K820140103http://www.reuters.com/article/2014/01/03/us-e-cigarette-idUSBREA020K820140103http://www.reuters.com/article/2014/01/03/us-e-cigarette-idUSBREA020K820140103


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FDA Warns of Health Risks Pos ed by E-Cigaret tes

The Food and Drug Administration (FDA) has joined other health experts to warnconsumers about potential health risks associated with electronic cigarettes.

Also known as "e-cigarettes," electronic cigarettes are battery-operated devicesdesigned to look like and to be used in the same manner as conventional cigarettes.

Sold online and in many shopping malls, the devices generally contain cartridges filledwith nicotine, flavor, and other chemicals. They turn nicotine, which is highly addictive,and other chemicals into a vapor that is inhaled by the user.

The FDA is concerned about the safety of these products and how they are marketed

to the public, says Margaret A. Hamburg, M.D., commissioner of food and drugs.

The agency is concerned that

e-cigarettes can increase nicotine addiction among young people and may lead kidsto try other tobacco products, including conventional cigarettes, which are known tocause disease and lead to premature death

the products may contain ingredients that are known to be toxic to humans

because clinical studies about the safety and efficacy of these products for theirintended use have not been submitted to FDA, consumers currently have no way ofknowing 1) whether e-cigarettes are safe for their intended use, or 2) about whattypes or concentrations of potentially harmful chemicals or what dose of nicotine they

are inhaling when they use these products.

The potential health risks posed by the use of e-cigarettes were addressed in a July 22,2009, phone conference between Joshua M. Sharfstein, M.D., principal deputycommissioner of food and drugs; Jonathan Winickoff, M.D., chair of the American

Academy of Pediatrics Tobacco Consortium; Jonathan Samet, M.D., director of theUniversity of Southern California's Institute for Global Health; and Matthew T. McKenna,


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M.D., director of the Office on Smoking and Health at the national Centers for DiseaseControl and Prevention.

Conference participants stressed the importance of parents being aware of the healthand marketing concerns associated with e-cigarettes. It was stated that parents may

want to tell their children and teenagers that these products are not safe to use.

Of particular concern to parents is that e-cigarettes are sold without any legal agerestrictions, and are available in different flavors (such as chocolate, strawberry andmint) which may appeal to young people.

In addition, the devices do not contain any health warnings comparable to FDA-approved nicotine replacement products or conventional cigarettes.

During the phone conference, which was shared with the news media, FDA announcedfindings from a laboratory analysis that indicates that electronic cigarettes expose users

to harmful chemical ingredients.

FDAs Division of Pharmaceutical Analysispart of the agency's Center for DrugEvaluation and Researchanalyzed the ingredients in a small sample of cartridgesfrom two leading brands of e-cigarette samples.

One sample was found to contain diethylene glycol, a toxic chemical used in antifreeze.Several other samples were found to contain carcinogens, including nitrosamines.

Agency Act ions

FDA has been examining and detaining shipments of e-cigarettes at the border and hasfound that the products it has examined thus far meet the definition of a combinationdrug device product under the Federal Food, Drug, and Cosmetic Act. The agency hasbeen challenged regarding its jurisdiction over certain e-cigarettes in a case currentlypending in federal district court.

FDA is planning additional activities to address its concerns about electronic cigarettes.

Meanwhile, health care professionals and consumers may report serious adverseevents or product quality problems with the use of e-cigarettes to FDA through the MedWatch program, either online or by phone at 1-800-FDA-1088.

REFERENCE

http://www.fda.gov/forconsumers/consumerupdates/ucm173401.htm
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Are Electronic Cigaret tes A Safe Alternative For Smokers?

KNUTSFORD, UNITED KINGDOM - JULY 05: In this photo illustration a womansmokes an electronic cigarette on July 5, 2012 in Knutsford, United Kingdom. Electronic

cigarettes are the latest health device for smokers hoping to quit nicotine addiction.

Earlier today a major security operation took place in Staffordshire, England, after a

passenger on a coach used an electronic cigarette which was mistaken for something

more sinister and a full scale security alert was instigated. The 48 passengers were

later allowed to carry on with their journey. (Image credit: Getty Images via @daylife)

Electronic cigarettes have recently been marketed and promoted as a safe alternative

to traditional tobacco smoking, but based on recent research, this popular and growing

trend could be just as harmful to your lungs and overall health. It is estimated that nearly700,000 people currently use these electronic pens in order to quit smoking.

Electronic cigarettes deliver nicotine through a vapor as opposed to smoke. Although no

combustion is involved, the nicotine is still derived from tobacco. This method of delivery

has been thought to be potentially less harmful than smoking tobacco. The devices are

imported from China and their nicotine content is currently not regulated prior to sale or

distribution.

Astudypresented at the European Respiratory Societys annual meeting in

Vienna in February, 2012 demonstrated an abrupt increase in airway resistance leadingto a lower level of oxygen in the bloodstream in electronic cigarette users. This could

have dangerous effects on people with coronary artery disease who have obstructing

plaques in their coronary arteries. In their small study, theAthensresearchers studied

the effects of the electronic cigarettes on 8 people who never smoked, along with 24

smokers-11 with normal lung function and 13 participants with asthma or chronic
http://www.ersnetsecure.org/public/prg_congres.abstract?ww_i_presentation=59718http://www.ersnetsecure.org/public/prg_congres.abstract?ww_i_presentation=59718http://www.ersnetsecure.org/public/prg_congres.abstract?ww_i_presentation=59718http://www.forbes.com/places/ga/athens/http://www.forbes.com/places/ga/athens/http://www.forbes.com/places/ga/athens/http://www.forbes.com/places/ga/athens/http://www.ersnetsecure.org/public/prg_congres.abstract?ww_i_presentation=59718


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obstructive pulmonary disease (COPD). The study participants all used an electronic

cigarette for 10 minutes. Researchers then conducted measurements of airway

resistance and lung function. All participants had a sudden increase in airway resistance

which lasted about 10 minutes. Interestingly, the increase was more noticeable in

smokers than non smokers, although the effect seen in people with COPD was less

immediate in nature. The researchers stated that it was unclear whether this increase in

resistance had any potential long term effects.

The European Respiratory Society (ERS) smoking cessation guidelines do not currently

recommend the use of such electronic products. A number of physicians in the ERS

note that a number of brands of e- cigarettes contain high levels of nicotine which is

highly addictive, and also linked to development of lung cancer.

According to Dr. Klaus Lessnau, a pulmonary and critical care specialist at Lenox Hill

Hospital inNew YorkCity, tobacco cigarettes are the leading preventable cause of

death and disease in the US. He went on to state that although electronic cigarettes

cannot be recommended to improve lung health, there is certainly some degree of harm

reduction compared to regular cigarette use.

Dr. Lessnau explained that there are no major studies to date, but he believed that the

impact on lung cancer will be substantial. He explained that regular tobacco products

produce more than 1,000 toxic substances, many of them tar relatedwhereas,

electronic cigarettes do not. He believes that cardiovascular disease including

myocardial infarction (heart attack) and stroke may not see any major impact, since

there is a connection with nicotine. Although there are no major studies to date, Dr.

Lessnau said that it is very conceivable that lung cancer will be decreased.

In reality, limited conclusions can be drawn from the preliminary findings of the small

study presented in this article. However, data from this study does add to growing

evidence of the harmful effects of e-cigarettes. Well-established methods that can help

you quit smoking such as nicotine gum, patches, and inhalers are known as nicotine

replacement therapy (NRT), and are an advisable alternative to electronic cigarettes.

Regulating the nicotine content of these electronic cigarettes is the next priority, along

with their safety and quality.

REFERENCEhttp://www.forbes.com/sites/robertglatter/2012/10/30/are-electronic-cigarettes-a-safe-alternative-for-smokers/
http://www.forbes.com/places/ny/new-york/http://www.forbes.com/places/ny/new-york/http://www.forbes.com/places/ny/new-york/http://www.forbes.com/sites/robertglatter/2012/10/30/are-electronic-cigarettes-a-safe-alternative-for-smokers/http://www.forbes.com/sites/robertglatter/2012/10/30/are-electronic-cigarettes-a-safe-alternative-for-smokers/http://www.forbes.com/sites/robertglatter/2012/10/30/are-electronic-cigarettes-a-safe-alternative-for-smokers/http://www.forbes.com/sites/robertglatter/2012/10/30/are-electronic-cigarettes-a-safe-alternative-for-smokers/http://www.forbes.com/sites/robertglatter/2012/10/30/are-electronic-cigarettes-a-safe-alternative-for-smokers/http://www.forbes.com/places/ny/new-york/


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Smoking Cessat ion Health Center

E-Cigarettes 101

ByR. Morgan Griffin

Electronic cigarettes: Are they safer than tobacco? Or are they a high-tech way to hook

a new generation on a bad nicotine habit?

Nobody knows yet.

Research into the effects of e-cigarettes lags behind their popularity. But ready or not,

the era of e-cigarettes is here. Its a booming, billion-dollar industry -- on track to outsell

tobacco products within a decade. The number of teens and tweens using these

products doubled between 2011 and 2012.

The time to get informed about these products is now.

How E-Cigarettes Work

They look like the real thing. The end glows as you inhale. As you exhale, you puff out a

cloud of what looks like smoke. It's vapor, similar to the fog you might see at rock

shows, says M. Brad Drummond, MD. He's an assistant professor of medicine at Johns

Hopkins University School of Medicine.

All e-cigarettes work basically the same way. Inside, there's a battery, a heating

element, and a cartridge that holds nicotine and other liquids and flavorings. Features

and costs vary. Some are disposable. Others have a rechargeable battery and refillable

cartridges.

Using an e-cigarette is called "vaping."

Are They Safe?

The nicotine inside the cartridges is addictive. When you stop using it, you can get

withdrawal symptoms including feeling irritable, depressed, restless and anxious. It can

be dangerous for people withheartproblems. It may also harm yourarteriesover time.

So far, evidence suggests that e-cigarettes may be safer than regular cigarettes. The

biggest danger from tobacco is the smoke, and e-cigarettes don't burn. Tests show the

levels of dangerous chemicals they give off are a fraction of what you'd get from a real

cigarette. But what's in them can vary.
http://www.webmd.com/r-morgan-griffinhttp://www.webmd.com/r-morgan-griffinhttp://www.webmd.com/r-morgan-griffinhttp://www.webmd.com/heart/picture-of-the-hearthttp://www.webmd.com/heart/picture-of-the-hearthttp://www.webmd.com/heart/picture-of-the-arterieshttp://www.webmd.com/heart/picture-of-the-arterieshttp://www.webmd.com/heart/picture-of-the-arterieshttp://www.webmd.com/heart/picture-of-the-arterieshttp://www.webmd.com/heart/picture-of-the-hearthttp://www.webmd.com/r-morgan-griffin


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"E-cigarettes may be less harmful than cigarettes," Drummond says. "But we still don't

know enough about their long-term risks or the effects of secondhand exposure."

Pro and Con

E-cigarettes have triggered a fierce debate among health experts who share the samegoal -- reducing the disease and death caused by tobacco. But they disagree about

whether e-cigarettes make the problem better or worse.

Opponents say that because nicotine is addictive, e-cigarettes could be a "gateway

drug," leading nonsmokers and kids to use tobacco. They also worry that manufacturers

-- with huge advertising budgets and celebrity endorsements -- could

makesmokingpopular again. That would roll back decades of progress in getting

people to quit or never start smoking.

Others look at possible benefits for smokers. "Obviously, it would be best if smokers

could quit completely," says Michael Siegel, MD, MPH, a professor at Boston

University's School of Public Health. "But if that's not possible, I think they'd be a lot

better off with e-cigarettes. They're a safer alternative."

Siegel compares replacing tobacco with e-cigarettes to heroin users switching to the

painkiller methadone. The replacement may have its own risks, but it's safer.

Some supporters believe that e-cigarettes could help people quit, just like nicotine gum.

Research hasn't shown that yet, though.

REFERENCEhttp://www.webmd.com/smoking-cessation/features/electronic-cigarettes
http://www.webmd.com/smoking-cessation/default.htmhttp://www.webmd.com/smoking-cessation/default.htmhttp://www.webmd.com/smoking-cessation/default.htmhttp://www.webmd.com/smoking-cessation/features/electronic-cigaretteshttp://www.webmd.com/smoking-cessation/features/electronic-cigaretteshttp://www.webmd.com/smoking-cessation/features/electronic-cigaretteshttp://www.webmd.com/smoking-cessation/default.htm


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E-c igaret tes: m irac le or heal th r isk?

More than two million people in the UK get their nicotine hit via electronic cigarettes. But

as 'vaping' replaces smokingand is enthusiastically marketed by the beleaguered

tobacco giantsno one is yet sure how safe it actually is

A customer at the Vape Lab in Shoreditch, London, samples the wares. Photograph:Sean Smith for the Guardian

In 1963, a young Korean war veteran and committed 40-a-day smoker calledHerbert AGilbertfrom Beaver Falls, Pennsylvania, filed apatent for a product he described as a

"smokeless non-tobacco cigarette".It functioned by gently heating a nicotine solution

and producing inhalable steam, thereby "replacing burning tobacco and paper withheated, moist, flavoured air".

As the health risks of tobacco-smokingslowly began to emerge, Gilbert hopefully touted

his device around the big tobacco and medical supplies companies. Several professedinterest, butat a time when, in Britain alone, some 70% of adult males were regularsmokersnone apparently saw enough potential in his oddball invention to put anymoney into it.Half a century on, after a decisive intervention by a Chinese pharmacist called Hon Lik,

whose company Ruyan (literally, "Resembling Smoking") began exporting its version ofthe electronic cigarette in the mid-2000s, andperhaps just as importantthewidespread outlawing of tobacco smoking in enclosed public spaces in many westerncountries, the potential has become clearer.

In 2013, according toa survey by YouGovfor the anti-tobacco charityAsh(Action on

Smoking and Health), the number of e-cigarette users in the UK surged to 2.1 million, athree-fold increase over the previous year. The investment bank Goldman Sachs puts
http://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.htmlhttp://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.htmlhttp://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.htmlhttp://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.htmlhttps://www.google.com/patents/US3200819https://www.google.com/patents/US3200819https://www.google.com/patents/US3200819https://www.google.com/patents/US3200819http://www.theguardian.com/society/smokinghttp://www.theguardian.com/society/smokinghttp://www.theguardian.com/society/smokinghttp://www.theguardian.com/society/2014/apr/28/e-cigarette-users-triple-ash-surveyhttp://www.theguardian.com/society/2014/apr/28/e-cigarette-users-triple-ash-surveyhttp://www.theguardian.com/society/2014/apr/28/e-cigarette-users-triple-ash-surveyhttp://www.ash.org.uk/http://www.ash.org.uk/http://www.ash.org.uk/http://www.ash.org.uk/http://www.theguardian.com/society/2014/apr/28/e-cigarette-users-triple-ash-surveyhttp://www.theguardian.com/society/smokinghttps://www.google.com/patents/US3200819https://www.google.com/patents/US3200819http://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.htmlhttp://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.html


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the products top of a list of "creative destroyers" including big data, 3D printing andnatural gas enginesthat are likely to turn their markets upside down, and sees annualglobal sales of e-cigarettes hitting $10bn within a few years.ForV-Revolutionin Covent Garden, which claims to be London's first shop dedicatedexclusively to e-cigarettes, that means business is brisk. Since opening last May, the

store has seen a 90% increase in custom, says assistant manager Elizabeth Playle. Itnow sells well over 50 reusable e-cigarettes a dayat prices, depending on their sizeand voltage, ranging from 25 to 90 eachplus many more bottles of e-juice, theliquid mixture of nicotine, flavourings and dilutants that the devices vapourise. Internetsales are booming."It's really, really taken off," says Playle, as a steady stream of dedicated vapers (asusers are known) file in, try out a new flavour some emulate the taste of traditionalcigarettes, such as Chesterfield, Marlboro Red or Camel; others taste of apple, coffee,berries, tropical fruit, even pia coladaand hand over their 7.99 for a 20ml bottle,generally enough for the equivalent of around 200 cigarettes.

Playle's French-born assistant, Joelle Tabone ("Vaping is huge in France; every smalltown has at least one shop"), explains how they work. These are second-generation e-cigarettes, a step on from the disposable "cig-a-likes"so called because they closelyresemble a tobacco cigarettewhich contain the "puff equivalent" of around 30cigarettes and can be bought over the counter in corner shops and chemists for about7 each.

Elizabeth Playce and

Joelle Tabone of the V-Revolution e-cigarette shop in Covent Garden, London.

Photograph: Linda Nylind for the Guardian

As you puff, the battery at the far end of the device powers a tiny electronic heatingelement, the atomiser, contained in the clear, refillable cartridge (the "clearomizer")attached to the mouthpiece. The e-liquid in the clearomizer, drawn on to the heatingelement by fibre wicks, disappears in a cloud of scented vapour, some of which youinhale (the rest evaporates).
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The e-juice is available in three different nicotine strengths, and more sophisticateddevices also let users adjust their e-cigarette's voltage to vary the potency of the "hit"they get. The idea, essentially, is that e-cigarettes deliver all the sensations of smoking,plus the all-important nicotine, without the 70-odd carcinogenic chemicals that tobaccocigarettes generally deliver as well.

Logically, by far their biggest users are smokers. According to Ash's survey, nearly two-thirds of e-cigarette users in the UK are current smokers seeking to cut down or give upaltogether, while the remaining third are ex-smokers who have already stopped and arekeen not to restart. Only 0.1% of e-cigarette users are nonsmokers.

That certainly chimes with Playle's experience: the "overwhelming majority" of V-Revolution's customers are tobacco smokers who want to stop, she says some ofthem on their doctors' orders. "I would never promote these as a 'healthy option',because the only good smoking is no smoking," she says. "But when someone hasbeen told they must give up, and they come in here and start using these You seethe difference."

So far, so marvellous: on the face of it, e-cigarettes look like a near-miraculousinnovation in tobacco harm reduction. By theWorld Health Organisation's estimates,

tobacco kills half its users and six million people each year die from the direct andindirect effects of smoking. But the public health community is deeply divided over e-cigarettes. "Some people think they're fantastic, the miracle product that is going to stoppeople smoking cigarettes," says Anna Gilmore, director of theTobacco ControlResearch Group at the University of Bathand UK Centre for Tobacco and Alcohol

Studies. "Others think they're a potential disaster, because nicotine is an addictive drugand because e-cigarettes may re-normalise smoking."

As far as the health risk is concerned, it is fair to say, as Gilmore notes, that "e-

cigarettes are certain to be way less harmful than cigarettes. Common sense woulddictate that." But equally, while early tests appear to be at least partially reassuring, e-cigarettes have simply not been around long enough for there to be any reliable long-term studies of the risk they might represent.

The World Health Organisation (WHO) calls the devices' safety "illusive",noting that the

chemicals they contain are often not disclosed and have not been properly tested .The

US Federal Centers for Disease Control (CDC) has said there is "enough evidence" tosay that switching to electronic cigarettes would "likely be healthier" than smoking. Butmainly because of the near complete lack of regulatory oversight, and because e-cigarettes do, after all, contain nicotine, which is far from being a "benign substance",the CDC will not go so far as to pronounce them safe either.The British Medical Association (BMA) has also warned it is worried by the lack of peer-reviewed studies on e-cigarette safety, and public health officials elsewhere haveexpressed concerns about the purity of the products' ingredients, the precise dose ofnicotine delivered by different devices and liquids, inaccurate product labelling and anoverall lack of quality control in the manufacturing process. "The real truth," saysGilmore, "is that we just do not know. We cannot say e-cigarettes are risk-free. Wecannot yet be sure what impact they will have on smoking rates or population health,whether they'll be the miracle product or not."
http://www.who.int/mediacentre/factsheets/fs339/en/http://www.who.int/mediacentre/factsheets/fs339/en/http://www.who.int/mediacentre/factsheets/fs339/en/http://www.bath.ac.uk/health/research/tobacco-control/http://www.bath.ac.uk/health/research/tobacco-control/http://www.bath.ac.uk/health/research/tobacco-control/http://www.bath.ac.uk/health/research/tobacco-control/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/http://www.who.int/tobacco/communications/statements/eletronic_cigarettes/en/http://www.bath.ac.uk/health/research/tobacco-control/http://www.bath.ac.uk/health/research/tobacco-control/http://www.who.int/mediacentre/factsheets/fs339/en/


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Nor is there unanimous agreement among public health experts that e-cigarettes evenhelp people to give up smoking. WHO has said their efficacy as an aid in giving upsmoking is "yet to be demonstrated", adding that it "strongly advises" consumers not touse them until national regulatory bodies have declared them both effective and safe.Similarly, the BMA currently encourages doctors to recommend other nicotine

replacement therapies ahead of e-cigarettes (although it says that for patients who areunwilling to use nicotine gum or patches, or tried them unsuccessfully, the devices canbe presented as a lower-risk option than smoking tobacco).

Many experts, including Ash's former director, Clive Bates, feel strongly that any risksassociated with e-cigarettes are outweighed by their capacity to dramatically take theharm out of using nicotine. Others, equally strongly, disagree, arguing that even if e-cigarettes turn out to be perfectly safe, they risk re-normalising what is now, in mostdeveloped countries, a pariah habit: a "lifestyle product" that is actually a way to get, orkeep, people hooked on the real thing.

UK studiesseem to suggest little evidence that e-cigarettes might have this effect. But

ina study of 40,000 young Americansunambiguously entitled E-Cigarettes: Gateway to

Nicotine Addiction for US Teens, the University of California's Center for TobaccoResearch and Education found that using e-cigarettes was likely to increase theprobability of experimenting with traditional cigarettes.

And somemore outspoken (and, in the vaping community, much-vilified) opponents of

e-cigarettessuch as Martin McKee, professor of European Public Health at the London

School of Hygiene and Tropical Medicine, argue that the high proportion of vapers whoalso continue to smoke tobacco means that many are, basically, kidding themselves.Far from having a major positive impact on public health, the anti camp believes, thewhole e-cigarette phenomenon is really about encouraging "dual use" of e-cigarettesand tobacco, boosting tobacco companies' profits at a time when sales in the developed

world are falling fast, as well as buying them some much-needed credibility.

E-cigarettes are now becoming big business. Photograph: Sean Smith for the Guardian
http://www.bbc.co.uk/news/health-27161965http://www.bbc.co.uk/news/health-27161965https://www.ucsf.edu/news/2014/03/112316/e-cigarettes-gateway-nicotine-addiction-us-teens-says-ucsf-studyhttps://www.ucsf.edu/news/2014/03/112316/e-cigarettes-gateway-nicotine-addiction-us-teens-says-ucsf-studyhttps://www.ucsf.edu/news/2014/03/112316/e-cigarettes-gateway-nicotine-addiction-us-teens-says-ucsf-studyhttp://www.theguardian.com/society/2014/feb/21/boom-ecigarette-sales-divides-campaignershttp://www.theguardian.com/society/2014/feb/21/boom-ecigarette-sales-divides-campaignershttp://www.theguardian.com/society/2014/feb/21/boom-ecigarette-sales-divides-campaignershttp://www.theguardian.com/society/2014/feb/21/boom-ecigarette-sales-divides-campaignershttp://www.theguardian.com/society/2014/feb/21/boom-ecigarette-sales-divides-campaignershttp://www.theguardian.com/society/2014/feb/21/boom-ecigarette-sales-divides-campaignershttps://www.ucsf.edu/news/2014/03/112316/e-cigarettes-gateway-nicotine-addiction-us-teens-says-ucsf-studyhttp://www.bbc.co.uk/news/health-27161965


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And here, things start to get complicatedbecause the world's leading tobaccocompanies are busy turning themselves into leading players in the e-cigarettemarket.RJ Reynolds,Philip Morris,Japan Tobacco International,Imperial

Tobacco(which sells through Boots) andBritish American Tobacco(BAT) have alleither already launched e-cigarette lines, or have them in development and are

marketing them in almost exactly the same way as cigarettes used to be in the dayswhen tobacco advertising was still allowed."E-cigarettes are being marketed just like cigarettes were in the past," says Gilmore,pointing to aTV advertisement for Vype,the e-cigarette brand owned by BAT, which

featured an attractive young couple running through a cityscape before leaping into acloud of vapour promising of "pure satisfaction for smokers".Gilmore says e-cigarettes could be seen as "a godsend for thetobacco industry.With

cigarette companies selling e-cigarettes, there isn't the competition between e-cigarettes and cigarettes that would likely reduce tobacco-smoking. And just as their lastadvertising avenue for tobaccocigarette packetsis being closed down, tobaccocompanies can advertise e-cigaretteseffectively showing lots of pictures of people,

basically, smoking."Selling e-cigarettes also allows the tobacco companies access to the politicians andpublic health bodies who are currently debating how the vaping market should beregulated, Gilmore points outhandily circumventingArticle 5.3 of the WHO'sFramework Convention on Tobacco Control,which effectively bars the industry from somuch as talking to governments about public health policy in relation to tobacco. "Butnow they are selling e-cigarettes, they can claim to be on the side of the angels," shesays. "It just really muddies the waters."Governments are still uncertain about how to respond to e-cigarettes. Some, as in theUK, want to regulate them essentially as medicinesas aids to quitting smokingmeaning they will be subject to the same rules on, for example, ingredient quality as

apply to nicotine patches and gum.The WHO and US seem to favor regulating e-cigarettes in exactly the same way astobacco, with strict advertising rules and heavy taxation. The EU looks to be somewherein the middle, proposing both controls on ingredients and nicotine strength andmarketing restrictions. Some countries, such as Brazil, have simply banned themoutright, while many local authoritiesincluding New York City, Chicago and Los

Angeles, and have outlawed their use in public places, just like tobacco. With passionsrunning high on both sides, the debate around e-cigarettes seems unlikely to be settledany time soon.

REFERENCE

http://www.theguardian.com/society/2014/may/05/rise-of-e-cigarettes-miracle-or-health-risk
http://en.wikipedia.org/wiki/R._J._Reynolds_Tobacco_Companyhttp://en.wikipedia.org/wiki/R._J._Reynolds_Tobacco_Companyhttp://en.wikipedia.org/wiki/R._J._Reynolds_Tobacco_Companyhttp://en.wikipedia.org/wiki/Philip_Morris_Internationalhttp://en.wikipedia.org/wiki/Philip_Morris_Internationalhttp://en.wikipedia.org/wiki/Philip_Morris_Internationalhttp://en.wikipedia.org/wiki/Japan_Tobacco_Internationalhttp://en.wikipedia.org/wiki/Japan_Tobacco_Internationalhttp://en.wikipedia.org/wiki/Japan_Tobacco_Internationalhttp://en.wikipedia.org/wiki/Japan_Tobacco_Internationalhttp://en.wikipedia.org/wiki/British_American_Tobaccohttp://en.wikipedia.org/wiki/British_American_Tobaccohttp://en.wikipedia.org/wiki/British_American_Tobaccohttp://www.youtube.com/watch?v=quAMUXNeY6Yhttp://www.youtube.com/watch?v=quAMUXNeY6Yhttp://www.youtube.com/watch?v=quAMUXNeY6Yhttp://www.theguardian.com/business/tobacco-industryhttp://www.theguardian.com/business/tobacco-industryhttp://www.theguardian.com/business/tobacco-industryhttp://www.who.int/fctc/guidelines/article_5_3.pdfhttp://www.who.int/fctc/guidelines/article_5_3.pdfhttp://www.who.int/fctc/guidelines/article_5_3.pdfhttp://www.who.int/fctc/guidelines/article_5_3.pdfhttp://www.theguardian.com/society/2014/may/05/rise-of-e-cigarettes-miracle-or-health-riskhttp://www.theguardian.com/society/2014/may/05/rise-of-e-cigarettes-miracle-or-health-riskhttp://www.theguardian.com/society/2014/may/05/rise-of-e-cigarettes-miracle-or-health-riskhttp://www.theguardian.com/society/2014/may/05/rise-of-e-cigarettes-miracle-or-health-riskhttp://www.theguardian.com/society/2014/may/05/rise-of-e-cigarettes-miracle-or-health-riskhttp://www.who.int/fctc/guidelines/article_5_3.pdfhttp://www.who.int/fctc/guidelines/article_5_3.pdfhttp://www.theguardian.com/business/tobacco-industryhttp://www.youtube.com/watch?v=quAMUXNeY6Yhttp://en.wikipedia.org/wiki/British_American_Tobaccohttp://en.wikipedia.org/wiki/Japan_Tobacco_Internationalhttp://en.wikipedia.org/wiki/Japan_Tobacco_Internationalhttp://en.wikipedia.org/wiki/Philip_Morris_Internationalhttp://en.wikipedia.org/wiki/R._J._Reynolds_Tobacco_Company


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The Pros and Cons of E-Cigarettes

You can smoke them virtually anywhere. Many say they will help you quit smoking, aplus for people withCOPDwho often struggle withsmoking cessation.Others are

skeptical and afraid to try them. The FDA would like to regulate them as medicalproducts. The e-cigarette industry feels that the FDA has no substantiated reason to doso. There's a lot of talk going on about e-cigarettes, so before making a decision to usethem, learn the facts about their pros and cons.What are E-Cigarettes?

Electronic cigarettes, or e-cigarettes for short, are battery-powered devices filled withliquidnicotine(a highly addictive chemical) that is dissolved in a solution of waterandpropylene glycol.Many of them look like real cigarettes, with a white cylindrical

tube, brown filter, and red-glowing tip. Others come in less conspicuous, darker colors.How Do They Work?

Often termed "vaping," when you take a puff on the end of the e-cigarette tube, abattery heats up the nicotine, which creates a vapor that is then inhaled into the lungs.The end result is a sensation of smoke in the mouth and lungs without really smoking.

The Upside to E-Cigarettes

Unlike tobacco products, there are no current laws in effect prohibiting the use of e-cigarettes in public places. Case in point, I work in a hospital and a fellow nurse smokesthem right there in the nursing station.

Here's what current research says about the positive aspects of this product:

In a study of 40 tobacco-dependent smokers, researchers concluded that smoking e-cigarettes alleviated the desire to smoke (after abstaining from smoking overnight),was well-tolerated, and pharmacologically more like a Nicolette inhaler than tobacco.

Another study of 50 smokers who wanted to reduce the health risks associated withsmoking, but not quit completely, concluded that the Eclipse brand of e-cigarettesdramatically decreased the consumption of cigarettes without causing withdrawalsymptoms. In addition, when participants smoked Eclipse, the nicotine concentrationsin their blood remained fairly stable and their desire to quit altogether remained intact.However, the study concluded that because the Eclipse increased carbon monoxideconcentrations in the blood, it may not be a safer choice of cigarette. On the otherhand, it caused few, significant adverse events.

In a case study series, the e-cigarette was found to help three study participants --who all had a documented history of repeated failed attempts at smoking cessationusing professional smoking cessation assistance methods -- quit smoking and remainabstinent for at least 6 months.

During an online survey conducted in 2010, researchers polled visitors ofwebsites and discussion forums dedicated to the use of the e-cigarette and smokingcessation. Of the 3,587 participants, 70% were former smokers, 61% were men, andthe median age was 41 years. On average, participants used the e-cigarette for
http://copd.about.com/od/copd/a/copdfacts.htmhttp://copd.about.com/od/copd/a/copdfacts.htmhttp://copd.about.com/od/copd/a/copdfacts.htmhttp://copd.about.com/od/quittingsmoking/tp/howtostopsmoking.htmhttp://copd.about.com/od/quittingsmoking/tp/howtostopsmoking.htmhttp://copd.about.com/od/quittingsmoking/tp/howtostopsmoking.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://quitsmoking.about.com/od/nicotine/p/nicotineprofile.htmhttp://copd.about.com/od/quittingsmoking/tp/howtostopsmoking.htmhttp://copd.about.com/od/copd/a/copdfacts.htm


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approximately 3 months, drew 120 puffs/day, and used 5 cartridges/day. Almost all ofthem used cartridges that contained nicotine. Ninety-six percent said that the e-cigarettehelped them quit smoking, while 92% said that it made them smoke less. A majority ofthe participants said the e-cigarette helped them fight cravings, cope with withdrawalsymptoms, and avoid relapsing on cigarettes.

The Downside of E-Cigarettes

If you are a savvy consumer, both positive and negative aspects of the the product youare considering should be scrutinized before you purchase it. The e-cigarette is noexception. Take a look at what some of the research says about the negative aspects ofthe e-cigarette:

A 2010 research paper published in Tobacco Controlsuggests that the e-cigarettelacks important regulatory factors, such as essential health warnings, proper labeling,

clear instructions on how to use them, and safe disposal methods. The authors of thestudy also found that some of the e-cigarette cartridges leaked, which could causetoxic exposure to nicotine.

A study published in the December 2011 issue of CHESTfound that the e-cigarettecaused acute pulmonary effects after smoking it for only five minutes, although studyauthors pointed out that these effects may not be of clinical significance. During thestudy, 40 healthy non-smokers (30 experimental/10 control) were asked to smoke thee-cigarette ad lib for five minutes. The experimental group used the e-cigarette withthe nicotine cartridge in place, while the control group smoked it with the nicotinecartridge removed.

After five minutes, lung function was assessed using a variety of tests. Resultsshowed that smoking the device for just five minutes caused an increase inimpedance, peripheral airway flow resistance, and oxidative stress in the lungs ofhealthy smokers (smokers who are not diagnosed with lung disease or chronic healthconditions.) They also pointed out that the study only measured results from smokingthe e-cigarette for five minutes -- because the average consumer is likely to smokethe e-cigarette many times a day, this might increase the risks. However, the authorssuggested that it is possible that if the e-cigarette were used as a short-term bridge tosmoking cessation, the benefits might outweigh the risks.

On their website, the FDA states that states that "E-cigarettes may contain

ingredients that are known to be toxic to humans, and may contain other ingredientsthat may not be safe." They also suggest that because e-cigarette manufacturers arenot required to submit clinical study data to them, the public has no way of knowing"whether e-cigarettes are safe for their intended use, what types or concentrations ofpotentially harmful chemicals are found in these products, or how much nicotine theyare inhaling when they use these products." The FDA is also concerned that themarketing efforts of e-cigarettes may increase addiction to nicotine, especially inyoung people, encouraging them to experiment with real tobacco products.


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The Best Way To Quit Smoking

How you choose to quit smoking is a matter of personal choice. The best method is theone that works for you. With this in mind, doing whatever it takes to be successful -- andsafe -- is how many people ultimately approach it.

Consult your health care provider about differentstop smoking aids,includingnicotine

replacement therapy,quit smoking medications such as Clonidine and Wellbutrin,quit

smoking support groups,andeducational materials.

If you decide to try the e-cigarette, be sure to discuss this with your doctor and do yourhomework. Understand the pros, cons, and safety concerns, and then make aninformed decision. The most important thing to remember is, no matter how you do it;you are making the best decision of your life when you finally decide to quit smoking,especially if you have COPD.

REFERENCE

http://copd.about.com/od/quittingsmoking/a/E-Cigarettes.htm
http://copd.about.com/od/quittingsmoking/tp/stopsmokingaids.htmhttp://copd.about.com/od/quittingsmoking/tp/stopsmokingaids.htmhttp://copd.about.com/od/quittingsmoking/tp/stopsmokingaids.htmhttp://quitsmoking.about.com/od/nrts/tp/Nicotine-Replacement-Therapy-Choices.htmhttp://quitsmoking.about.com/od/nrts/tp/Nicotine-Replacement-Therapy-Choices.htmhttp://quitsmoking.about.com/od/nrts/tp/Nicotine-Replacement-Therapy-Choices.htmhttp://quitsmoking.about.com/od/nrts/tp/Nicotine-Replacement-Therapy-Choices.htmhttp://copd.about.com/od/quitsmokingsupport/quitsmokingsupportgroups.htmhttp://copd.about.com/od/quitsmokingsupport/quitsmokingsupportgroups.htmhttp://copd.about.com/od/quitsmokingsupport/quitsmokingsupportgroups.htmhttp://copd.about.com/od/quitsmokingsupport/quitsmokingsupportgroups.htmhttp://www.cdc.gov/tobacco/quit_smoking/cessation/index.htmhttp://www.cdc.gov/tobacco/quit_smoking/cessation/index.htmhttp://www.cdc.gov/tobacco/quit_smoking/cessation/index.htmhttp://copd.about.com/od/quittingsmoking/a/E-Cigarettes.htmhttp://copd.about.com/od/quittingsmoking/a/E-Cigarettes.htmhttp://copd.about.com/od/quittingsmoking/a/E-Cigarettes.htmhttp://www.cdc.gov/tobacco/quit_smoking/cessation/index.htmhttp://copd.about.com/od/quitsmokingsupport/quitsmokingsupportgroups.htmhttp://copd.about.com/od/quitsmokingsupport/quitsmokingsupportgroups.htmhttp://quitsmoking.about.com/od/nrts/tp/Nicotine-Replacement-Therapy-Choices.htmhttp://quitsmoking.about.com/od/nrts/tp/Nicotine-Replacement-Therapy-Choices.htmhttp://copd.about.com/od/quittingsmoking/tp/stopsmokingaids.htm


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Research o n E-c igaret tes Examin ing Health Effects

Natalie McGill

Introduction

With the look and feel of real cigarettes, electronic cigarettes are experiencing a boomin popularity. But as the product's popularity rises, so do the unknowns about its

potential impact on public health.

As scientific studies on e-cigarettes attempt to catch up with their popularity, it remains

to be seen if the products will be a boon to smoking cessation or a setback toward the

goal of cutting out nicotine for good.

E-cigarettes are battery-powered devices that convert nicotine into vapor. The products

are sold over the counter and are not subject to the same regulation as actual

cigarettes. A 2011 survey showed that about 21 percent of smokers had used e-

cigarettes at least once up from about 10 percent of smokers who took the same

Web survey in 2010, according to Center for Disease Control and Prevention study

published online in February in Nicotine & Tobacco Research. About 7 percent of

smokers who received the same survey in 2010 via postal mail also said they had tried

e-cigarettes at least once.

The Food and Drug Administration announced in 2011 that the agency plans to propose

regulating e-cigarettes as a tobacco product, according to Jennifer Haliski, a public

affairs officer for FDA's Center for Tobacco Products. Any product containing nicotine

from tobacco, unless marketed for therapeutic purposes, is considered a tobacco

product, according to the 2009 court case, Sottera Inc. v. Food and Drug Administration.

However, concrete regulations on e-cigarettes have yet to be issued, as the science is

still catching up.

"Further research is needed to assess the potential public health benefits and risks of

electronic cigarettes and other novel tobacco products," Haliski said.

Getting regular smokers to quit is a potential public health benefit of e-cigarettes, said

Maciej Goniewicz, PhD, an assistant professor of oncology at the Roswell Park Cancer

Institute's Division of Cancer Prevention and Population Sciences.

Goniewicz said that so far he sees e-cigarettes being mostly used by regular smokers

rather than first-time smokers as an alternative to smoking cigarettes, offering


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another chance to quit after a relapse. Goniewicz is one of five authors of a Nicotine &

Tobacco Researchstudy published online in April 2012 that compared nicotine and

organic compound vapors of 16 e-cigarette brands available in U.S., United Kingdom

and Polish markets. The study found 300 puffs of e-cigarettes labeled as having high

nicotine levels delivered 0.5 to 15.4 milligrams of nicotine considered negligiblecompared to toxins in regular cigarettes.

However, Goniewicz said there is limited data about whether what is exhaled from e-

cigarettes contributes to exposure for people besides the user.

"We know there's almost nothing there compared to cigarette smoke," Goniewicz

told The Nation's Health. "But we don't know what's going on after a very long exposure.

We need to wait for the studies."

Regular use of nicotine, which is found in tobacco, is not without its own health effects.

An addictive substance, nicotine use can lead to increased blood pressure and heart

rate as well as nausea, sweating and diarrhea, according to the National Institutes of

Health. E-cigarettes are not the only product to deliver nicotine to users. A variety of

products are used to provide nicotine to users as a tool for smoking cessation, but such

tools are regulated by FDA.

FDA-approved over-the-counter cessation products include nicotine replacement

chewing gum, lozenges and skin patches. In addition, FDA regulates prescription drugs

that block nicotine's effects on a smoker's brain.

Tim McAfee, MD, MPH, director of CDC's Office on Smoking and Health and an APHA

member, said it is reasonably certain that if someone who smoked a pack a day

switched completely to e-cigarettes it could represent a benefit to health, but there are

still many "caveats and 'buts' around that."

One concern is the use of e-cigarettes in businesses or restaurants to skirt clean air

ordinances or indoor smoking bans, McAfee said. Use of e-cigarettes in places with

established indoor smoking laws could be a step backward for public health when it

comes to air quality, as well as a negative for someone who may have otherwise quit

nicotine, he said.

"Someone should not have to go in a restaurant and wonder what's coming out of a

plastic device that is completely unregulated," McAfee said. "And we know that nicotine


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comes out, which is not fair to expose people to in a public space, since nicotine is a

psychoactive substance."

In Washington, D.C., two members of the Council of the District of Columbia are not

waiting for more studies before proposing regulations.

Councilmembers Yvette Alexander and David Grosso introduced legislation April 9 to

classify e-cigarettes as regular cigarettes that are already prohibited in indoor areas in

the city.

Alexander, who chairs the Council's Committee on Health, said her council staff told her

that they had seen people using e-cigarettes inside city bars and restaurants. On a

subsequent trip to a convenience store to find one, a man told Alexander he had

searched for the device in a quest to quit smoking, she said.

"These e-cigarettes are marketed in one way in that if you want to smoke you can

smoke indoors," Alexander told The Nation's Health. "You can beat the ban by smoking

these e-cigarettes, that's one marketing tool."

Alexander noted that e-cigarettes are also touted as an alternative for people trying to

quit smoking. However, it is uncertain if they are less addictive than traditional

cigarettes.

"Everyone is up in arms that I'm trying to ban the e-cigarettes," Alexander said. "I'm justtrying to ban them as the same way tobacco products are banned indoors. If you want

to purchase them and smoke them in places where you can smoke tobacco products,

that's fine. But we just want to maintain the ban on tobacco products for indoor use."

Another potential public health concern is how the product is marketed toward teens

and young adults. According to CDC, teens who use smokeless tobacco are more likely

than nonusers to smoke cigarettes, which is a trend CDC's McAfee said he does not

want to see replicated with e-cigarettes.

Jennifer Pearson, PhD, MPH, a research investigator at the Schroeder Institute for

Tobacco Research and Policy Studies at the American Legacy Foundation, said that e-

cigarettes are a novelty product for young adults, along the lines of hookah. Pearson is

a co-author of a study on e-cigarette awareness published in the September issue of

APHA'sAmerican Journal of Public Health.


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"It's (seen as) something fun, different you can do when you go out and something you

can do in the clubs because you're not going to get kicked out," Pearson said.

E-cigarettes continue to evolve, with new models in the absence of federal regulation.

Goniewicz said that rather than limit access to the product, he would prefer thatregulations ensure quality and safety and prevent advertising to children.

"My point of view is that we still have cigarettes, and this is the main problem,"

Goniewicz said.

REFERENCEhttp://www.medscape.com/viewarticle/813587
http://www.medscape.com/viewarticle/813587http://www.medscape.com/viewarticle/813587http://www.medscape.com/viewarticle/813587


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Do e-c igaret tes help smokers qui t?

These battery-powered electronic cigarettes deliver vaporized nicotine without

tobacco, tar, or other chemicals

Consumer Reports magazine: May 2012

More than 45 million Americans smoke cigarettes, the leading preventable cause ofdeath in the U.S. Unfortunately, some stop-smoking methods, including nicotine gumand patches, are less effective than previously thought, according to a recent study inthe journal Tobacco Control.

Enter battery-powered electronic cigarettes, which deliver vaporized nicotine withouttobacco, tar, or other chemicals in regular cigarettes. (But nicotine itself has health risksof its own and is extremely addictive.) Their battery heats a cartridge of liquid nicotinesolution, creating an aerosolized mist that the user puffs, or vapes.

Though e-cigarettes emit no smoke, they deliver an experience like smoking, includingthe way theyre held and the LED tip. Last year, 2 .5 million Americans tried one. Thecost: up to $100 for a starter kit, which often includes the e-cig unit, two rechargeablelithium batteries, and five flavor cartridges. (Each cartridge equals roughly one pack ofcigarettes.)

Fans and foesProponents of e-cigarettes say theyre more healthful than the conventional type andthat they might help smokers quit tobacco. Some research backs that up. In a studypublished last year in the International Journal of Clinical Practice, researchersinterviewed more than 100 e-cigarette users and found that most were former smokerswho had used the devices to help them quit. Theyd tried to stop smoking previously an

average of nine times, and two-thirds had tried a cessation drug approved by the Foodand Drug Administration. A recent review of the available (albeit meager) scientificevidence on e-cigarettes in the Journal of Public Health Policy concluded thatelectronic cigarettes show tremendous promise in the fight against tobacco-relatedmorbidity and mortality.

Critics say that too little is known about the safety of e-cigarettes, which areunregulated. Some experts also worry that their availability onlinewhere a user need


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only click a box saying he or she is 18could entice children and teens to try them. Socould some of the flavors, such as pia colada and vanilla.

In 2010, the FDA tried to block the sale of some e-cigarette brands, arguing that theyremarketed as smoking-cessation devices, which the agency regulates. A courtdisagreed. Now, some states (including Mississippi, New Jersey, and Utah) and cities

have proposed or enacted bans on the sale or use of e-cigarettes.

Bot tom l ine. Talk to your doctor before trying to quit smoking with e-cigarettes.Because theyre not regulated, safety is a question and you use them at your own risk.

What users have repo rted to the FDANews reports that an electronic cigarette exploded in a Florida man's mouth in Februaryspurred us to file a Freedom of Information Act request to with the FDA to see what, ifany, adverse-event reports it has received on e-cigarettes since they came on the U.S.market in 2006. The agency responded in early March with 39 reports loggedthroughits adverse-event monitoring system.Of them, 31 dealt with negative health

effects; eight were complaints about customer service or positive comments about e-cigarettes.

Among the most common complaints were headache, dizziness, nausea, sleepiness,and coughing or other respiratory symptoms. There was only one report of an e-cigarette exploding and causing burns.

Adverse-event reports don't establish causality, nor can they show whether a personwas using a product as directed. On the other hand, the FDA estimates that it receivesonly 1 to 10 percent of all adverse events experienced by the public on products itregulates. Other people using e-cigarettes might have had symptoms but not reportedthem.

Either way, the reports underscore the need for the FDA to find a way to regulate e-cigarettes, which occupy a sort of regulatory no-mans land between smoking-cessationdevices and tobacco products. The agency told us that it plans to develop regulationsfor e-cigarettes, but no proposed rules have yet been issued.

REFERENCEhttp://consumerreports.org/cro/magazine/2012/04/do-e-cigarettes-help-smokers-quit/index.htm
http://www.fda.gov/Safety/MedWatch/HowToReport/ucm053074.htmhttp://www.fda.gov/Safety/MedWatch/HowToReport/ucm053074.htmhttp://www.fda.gov/Safety/MedWatch/HowToReport/ucm053074.htmhttp://consumerreports.org/cro/magazine/2012/04/do-e-cigarettes-help-smokers-quit/index.htmhttp://consumerreports.org/cro/magazine/2012/04/do-e-cigarettes-help-smokers-quit/index.htmhttp://consumerreports.org/cro/magazine/2012/04/do-e-cigarettes-help-smokers-quit/index.htmhttp://consumerreports.org/cro/magazine/2012/04/do-e-cigarettes-help-smokers-quit/index.htmhttp://consumerreports.org/cro/magazine/2012/04/do-e-cigarettes-help-smokers-quit/index.htmhttp://www.fda.gov/Safety/MedWatch/HowToReport/ucm053074.htm


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A new risk of electron ic cigaret tes

Soon-to-be-released study suggests the popular devices may releasecarcinogensJamie Kopf

On the eve of publication of new research that raises a major safety concern aboutelectronic cigarettes, eight U.S. senators last week called on the Food and Drug

Administration to take a hard look at the devices and the ways they're evolvingand toconsider the emerging risks as they move to adopt a final rule on electronic cigarettes.

In aletterdated May 8, 2014, the senators referenced a study to be published thisThursday, May 15, in the journal Nicotine and Tobacco Research. While the studyremains under embargo until then, a New York Times article published last weekhighlighted its key findings, namely that certain high-powered e-cigarettesknown as"tank systems"can reach high enough temperatures that they emit some of the samecarcinogens, including formaldehyde, found in traditional tobacco smoke. That'ssignificant, since one argument touted by e-cigarette proponents, andfrequently citedon sites that sell e-cigs,is that they don't produce the toxins associated with traditionalcigarette smoking.Do the FDA's proposed regulations for e-cigarettes go far enough?We don't thinkso.
http://www.markey.senate.gov/imo/media/doc/2014-5-8_Hamburg_E-Cigs.pdfhttp://www.markey.senate.gov/imo/media/doc/2014-5-8_Hamburg_E-Cigs.pdfhttp://www.markey.senate.gov/imo/media/doc/2014-5-8_Hamburg_E-Cigs.pdfhttp://www.consumerreports.org/cro/news/2014/04/don-t-trust-the-claims-on-e-cigarette-websites/index.htmhttp://www.consumerreports.org/cro/news/2014/04/don-t-trust-the-claims-on-e-cigarette-websites/index.htmhttp://www.consumerreports.org/cro/news/2014/04/don-t-trust-the-claims-on-e-cigarette-websites/index.htmhttp://www.consumerreports.org/cro/news/2014/04/don-t-trust-the-claims-on-e-cigarette-websites/index.htmhttp://www.consumerreports.org/cro/news/2014/04/fda-proposes-new-e-cigarette-regulations/index.htmhttp://www.consumerreports.org/cro/news/2014/04/fda-proposes-new-e-cigarette-regulations/index.htmhttp://www.consumerreports.org/cro/news/2014/04/fda-proposes-new-e-cigarette-regulations/index.htmhttp://www.consumerreports.org/cro/news/2014/04/fda-proposes-new-e-cigarette-regulations/index.htmhttp://www.consumerreports.org/cro/news/2014/04/fda-proposes-new-e-cigarette-regulations/index.htmhttp://www.consumerreports.org/cro/news/2014/04/fda-proposes-new-e-cigarette-regulations/index.htmhttp://www.consumerreports.org/cro/news/2014/04/don-t-trust-the-claims-on-e-cigarette-websites/index.htmhttp://www.consumerreports.org/cro/news/2014/04/don-t-trust-the-claims-on-e-cigarette-websites/index.htmhttp://www.markey.senate.gov/imo/media/doc/2014-5-8_Hamburg_E-Cigs.pdf


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The forthcoming study is expected to show that the carcinogens are released via thevapor that the user exhalesbasically the e-cigarette equivalent ofsecondhand smoke."It is important that the [FDA] recognize the potential health impacts associated not onlywith the d

are electronic cigarettes a public good or health hazard

Documents