Smoking goes electronic

‘Smoke healthy, smoke Lite-joy— A better alternative'; ‘Health e-cigarettes—Smoke and Quit Whenever'; 'Vapours- benefits of e-cigarettes'; 'Green-Smart-Living - easiest and most affordable way to start living a smoke-free life'... These are just a few of the several online advertisements one comes across these days— all glorifying electronic cigarettes.

Invented in 2003 by pharmacist Hon Lik of China, an electronic cigarette goes by different names—e-cigarette, electronic cigarette (EC), or electronic nicotine delivery system (ENDS). A typical EC, which often looks like a conventional cigarette, consists of rechargeable batteries, an atomizer, and a cartridge. The cartridge has the liquid containing propylene glycol, vegetable glycerine, flavourings and varying levels of nicotine. The battery heats the liquid which is vapourized in the atomizer and delivered to the lungs of the users who describe the experience as ‘vaping’ rather than smoking because the liquid inside the device vaporizes on pressing the button. Vaping is different from smoking in that a vaper takes longer and deeper puffs—typically between 200-300 daily, and 150 puffs are equivalent to 10 regular cigarettes.

Earlier ECs were manufactured by small companies in China. But as their market grows, Big Tobacco is embracing the e-cigarette business, marketing them aggressively and touting them as safer alternatives to traditional cigarettes, and even as smoking cessation tools. However, there is not sufficient scientific research that concludes ECs are effective tools to quit smoking.

Meanwhile the market for e-cigarettes increases exponentially and is currently valued at USD 2 billion, with the US accounting for a quarter of all sales (USD 500 million) in 2012 which were expected to double to USD 1 billion in 2013.

A recent report by the UK Medicines and Healthcare Products Regulatory Agency has found that the number of EC users in UK doubled to 1.3 million in 2013 from 700,000 in 2012, and currently 10% of UK smokers now use ECs. In the US the number of EC users increased from 16.4% in 2009 to 32.4% in 2010. A recent study by the U.S. Centres for Disease Control and Prevention shows that EC use doubled among U.S. middle and high school students during 2011–2012, resulting in an estimated 1.78 million students having ever used them.

According to Dr Charlotta Pisinger of Glostrup University Hospital, Denmark, “As these products are not currently regulated, there is misleading information on their contents which may not be even be disclosed by some manufacturers. There is also poor consistency between what is inside and what is labelled—at times labels without nicotine contain nicotine and labels with high nicotine contain almost no nicotine. The main ingredient propylene glycol is easily absorbed during inhalation and acute lung reactions have been recorded in the past. It is also feared to inhibit action of anti TB drugs. Other substances detected in the fluid are tobacco specific carcinogenic nitrosamines; toxic metals like cadmium, nickel and lead; carcinogenic carbonyls; toxic volatile organic compounds; and unapproved pharmacological active compounds. The conventional cigarette produces more particles initially, but the count converges to a similar scale as the aerosols of e-cigarettes condense.”

“The Food and Drug Administration (FDA) has reported an increasing number of adverse effects in EC users like chest pain, cough, shortness of breath, headache, nausea, dizziness. Severe Adverse Effects include hospitalization for illnesses like pneumonia, congestive heart failure, and seizure, second degree burns to the face (product exploded in user’s mouth), and loss of vision requiring surgery. A case of lipid pneumonia has also been recorded in a 42 year old woman where doctors found no other reason for it except the glycerine in EC.”

Impact on public health

A recent study suggests that e-cigarettes are not emission-free and their pollutants could be of health concern for users and second hand smokers. Dr Pisinger avers that, “Public health impact takes into account the level of risk as well as the number of persons exposed to it. If we have a low risk product affecting many persons or a high risk one affecting few persons, the public health impact will be same. As more and more people vape, the negative public health impact of ECs increases. Many non- smokers are likely to pick up vaping, as they believe that it is not dangerous. If we tell people that ECs are a great way to quit smoking, the danger is much greater. Quitting does not mean one can be on ECs. Focus must be on smoking cessation and not on switching to ECs.”

In the opinion of Dr Ehsan Latif, Director, Department of Tobacco Control at the International Union Against Tuberculosis and Lung Disease (The Union), ECs are trying to renormalize smoking habits. He is rightly worried about the global health implications of ECs which are touted by their vendors as healthy options to conventional cigarettes. He cautions that, “We as public health professionals need to learn from history and it gives me a déjà vu of the 1960s when cigarette companies told the public that their products are safe (but they were not). The same thing is happening with ECs. We do not know. We do not have any reports from drug and/or government regulatory authorities or scientific laboratories on what one is vaping actually. We are not even sure if the nicotine in ECs is chemical nicotine or is got from the tobacco leaves.”

“Efficacy studies need to be done to make sure that they can be used only for quitting (as is being claimed by the manufacturers) under prescribed environments. We do not have evidence right now and till we have it we cannot believe in one sided research claimed to be done by the producers of ECs. So till research has happened, regulations need to be put in place.”

Mr Bill Bellew of The Union laments that, The 5.4 million tobacco related deaths occurring every year are not due to a virus or bacteria, but because of the marketing tactics of tobacco companies. ECs are now their new target products. Their role is not clearly established. In some cases they are used as smoking cessation aids, while in other quarters they are used to maintain the addiction. The health impact of long time inhalation of propylene glycol—a lung irritant— is of concern and needs to be fully investigated. Some ECs have shown the presence of di ethylene glycol which has a history of mass poisonings and deaths. Use of e-cigarettes will undermine years of antismoking campaigns and do collateral damage in terms of unravelling the gains of smoke free policies.”

Dr Tara Singh Bam of the Union said to Citizen News Service (CNS) that in a survey done in Canada, UK, US and Australia, nearly three fourths of the respondents reported that they used ECs to obtain nicotine in smoke free spaces, indicating that ECs were being used also to satisfy nicotine addiction during periods of temporary abstinence.

International Response

E-cigarettes containing nicotine will be regulated as medicines in the United Kingdom only from 2016, to ensure their quality and safety. But Brazil, Norway and Singapore have already banned them completely and they are illegal in Indonesia with a warning from the Food and Drug Monitoring Agency, Indonesia that ECs could be more dangerous than regular cigarettes. In USA ECs that are marketed for therapeutic purposes are regulated by the Food and Drug Administration [FDA] Centre for Drug Evaluation and Research (CDER).

In December 2013, Michael Bloomberg, on the last day of his third term as mayor of New York City, signed a bill that lumped ECs into the Smoke Free Air Act, prohibiting vaping anywhere that smoking conventional tobacco products is banned.

Canada does not allow e-cigarettes containing nicotine to be sold in the country. It advises Canadians ‘not to use electronic cigarettes as the safety, quality and efficacy of these products remain uncertain, and they may pose health risks.’

In the South East Asian regional meeting of WHO Framework Convention on Tobacco Control (WHO FCTC), held in India in July 2013, all the participating nations backed India’s proposal for a total ban on ECs to prevent adverse impact on human health. This is in line with obligations under Article 5.2(b) of the WHO FCTC to prevent and reduce nicotine addiction.

The Union released a position statement on e-cigarettes at the 44th Union World Conference on Lung Health in Paris on 2 November 2013, strongly supporting the regulation of the manufacture, marketing and sale of ECs. In case their regulation as medicines is not feasible, the Union has proposed a comprehensive ban on their: advertising, promotion and sponsorship; sale to minors; use in public/work places; display in retail stores; promotion for tobacco cessation; use of flavours that appeal to children. It also wants consumer safety standards for EC cartridges to be established, including ensuring manufacturing consistency and regulating the maximum quantity/dosage of nicotine they may contain.

Also more worrying is the fact that ECs come in attractive colours and flavours like chocolate, mint, lemon, menthol, vanilla, candy, bubble gum, etc., with appealing names such as Mocha Madness, Cotton Candy, Bourbon, Cowboy and Cuban Supreme. They could be a potential gateway to new smokers, particularly among teenagers and in emerging/foreign markets, according to behavioural scientists at The University of Texas MD Anderson Cancer Centre. Scientists and medical professionals, meanwhile caution that long-term health effects of electronic cigarettes are unknown as yet. (CNS)