Wednesday, August 28, 2013

E Cigarettes

Harm reduction is a term we use often in both medicine and public health. The idea is a simple one: rather than offer one smack-down solution to a risky behavior (i.e. "Stop that"), we offer modifications to that behavior that are aimed at reducing bad outcomes (i.e. "If you are going to do that, let's help you do that more safely"). Those of us who are parents use a hybrid of the smack down and harm reduction on a rotating basis.  For example, in certain circumstances, we might find ourselves saying, "I am sorry, little dude, you are never ever allowed to jump off that curb on your skateboard into the street again."  But in a slightly different version of events, we may also find ourselves saying,"Okay, if you are going to keep jumping off the curb, let's at least get you a helmet and wrist guards, and please pick a curb that isn't a death trap."
Examples of harm reduction supported by current public policy include exchanging needles for people using injection drugs (to prevent the spread of HIV and Hepatitis C), supplying sex-workers with condoms (to prevent the transmission of sexually transmitted diseases), and teaching adolescents to use designated drivers when out drinking (to prevent accidents). These approaches are very different from the 'just say no' smack-down approach, and for some people, the idea of doing anything that supports peoples' bad behaviors rubs them really wrong. Crazy wrong.

Opponents to harm reduction argue that in tolerating risky behaviors (e.g. injection drug use, underage drinking), we send people the message that these are acceptable behaviors, and in framing the behavior as acceptable,  more vulnerable populations (e.g. children) will be initiated into those behaviors. Supporters of harm reduction argue that we must diversify our methodologies: avoidance of risky behaviors would be ideal, but it is essential to have options that can improve safety even if those options do nothing to extinguish the actual behaviors.

In my role as a family doctor, I have learned that if I don't consider the possibility of middle ground, I often find myself stuck in the same place (and all alone)-- this is particularly true with patients who aren't able or ready to make the changes that I am asking them to make. Then I fail. And so do my patients. So, right here, right now, I will confess that it's not entirely outside of my clinical repertoire to condone one of my alcoholic patient drinking a single beer every other day or my diabetic patient eating an occasional bowl of ice cream. Yes, you heard me right, harm reduction is in my bag of 'doctor tricks'.

This brings us to the latest harm reduction debate: E-Cigarettes.

E-Cigarettes (short for "electronic cigarettes") are battery-powered devices that deliver nicotine not through combustion or smoke, but rather through vaporizing or "vaping". Basically, a battery powers a heating element, which vaporizes a liquid solution (aka E-juice). E-juice usually contains a combination of  propylene glycol and/or vegetable glycerin, and/or polyethelyne glycol 400, some flavors and some varied concentration of nicotine (see box below for more specifics on these ingredients).

Most E-cigarettes are designed to look and feel like a 'real cigarettes', including the experience; the user actually gets a hot puff of gas when he/she inhales and sees a puff of vapor (not smoke) when he/she exhales. Some taste like a favorite brand.

There is no nasty smoke for a neighbor to inhale, no stink on your smoking jacket, and few official regulations. In fact, currently there is no federal or California law that restricts where people can use e-cigarettes (see this link for more details). In stark contrast to cigarette smoking, which is highly regulated, you can actually use e-cigarettes in most public places, like the airport, a restaurant, or even your doctor's office. Local jurisdictions can impose restrictions by adding e-cigarettes to their local definitions of "cigarette smoking", but many have not yet done so. 

"Starter kits" cost between $50-70 online, e-liquid refills cost around $2.50 for a 30mL bottle. Informal research shows individuals on average "vape" between 2-5ml/day, making e-cigarettes significantly cheaper than a pack per day habit of cigarettes (under $1/day for E-juice versus $6.45 for a pack of cigarettes in California).

I have several patients-- all long-time cigarette smokers-- who LOVE the e-cigarette alternative: many have never successfully quit tobacco, and they feel strongly that vaping is a healthier alternative to smoking. They spend less money on e-cigs than 'real cigarettes', they cough less, they stink less, and the world isn't nearly as annoyed with them and their vaping as they are with their cigarette smoking.

In fact, just this week, one of my e-cigarette smoking patients (with a history of smoking 2 packs per day for the last 40 years, now switched entirely to e-cigarettes) pulled one out and puffed right in front of me. I would have had no idea that anything happened if I hadn't been sitting there watching him do it.

Contents of E Cigarettes
Propylene glycol
A man-made liquid substance that absorbs water. Officially per the FDA, "generally recognized as safe" rating in food (GRAS), used as preservative in food, tobacco products, a solvent in drugs. But also found in antifreeze and solvents. More info here.
Vegetable glycerin
Made directly from vegetable oil (usually coconut, palm), used in manufactured food for sweetness, to keep things moist, also moisturizers (cosmetics), herbal essences, and common in cough medicines
Polyethylene glycol 400
Low molecular weight version of polyethylene glycol, often used industrial compound found in many consumer products, including automotive antifreeze, hydraulic brake fluids, some stamp pad inks, ballpoint pens, solvents, paints, plastics, films, and cosmetics.
A toxic colorless or yellowish oily liquid that is the chief active constituent of tobacco. Acts as a stimulant in small doses, but in larger amounts blocks the action of autonomic nerve and skeletal muscle cells. Nicotine is also used in insecticides
You know what this is!

Is this all creepy or awesome?

Depends on who you ask.

The Federal Drug Administration (FDA) and other public health agencies want e-cigarettes regulated. Initially, the FDA tried to block the sale of e-cigarettes entirely in the US, claiming that they were unapproved "drug and drug delivery combinations". E-cigarette manufacturers successfully challenged the FDA's position in court, and e-cigarettes were allowed into the US market in 2007.

Interestingly, e-cigarettes were not originally manufactured or distributed by the tobacco industry; in fact, they were invented in China in 2000 (legend says the pharmacist inventor's father actually died of lung cancer, and he was looking for an alternative to tobacco) and were direct competition with big tobacco when they arrived on the US market.  However, this year, three big tobacco companies have joined the mix and are now marketing their own e-cigarettes (see this story). 

Phew, thank goodness! I was starting to convince you (and myself) to actually like e-cigarettes. Now that we have big tobacco involved, things are automatically creepier. No doubt about it.

In 2010, a federal appeals court held that e-cigarettes could be regulated by the agency as tobacco products rather than as drugs or drug delivery combinations. Because e-cigarettes are now labelled as tobacco products, state and local governments officially have the authority to regulate the them under the Family Smoking Prevention and Tobacco Control Act. This means, for example, that it is prohibited to sell e-cigarettes to minors. Most recently the FDA is also threatening a ban on selling e-cigarettes on line.

The FDA would prefer that e-cigarettes be officially considered a "tool for smoking cessation" and/or nicotine replacement (i.e. things people use quit or cut back on smoking, like nicotine patches or nicotine gum) because this labeling would make the companies liable to FDA oversight. But e-cigarette companies are super duper smart--and a little slippery. They make no claim anywhere that e-cigarettes are designed to help people stop smoking. Instead, they offer e-cigarettes as a "recreational alternative" and  "safer alternative to smoking cigarettes" and/or "designed to be specifically used in places where people are not allowed to smoke" (increasingly in public places, airports, etc). This way, they skirt the FDA's oversight power. Hmmm. . .

States and local jurisdictions are definitely getting hip to the situation and are passing their own regulations. For example, in 2013 New Jersey enacted a law becoming the first state to prohibit the use of e-cigarettes in indoor public places and workplaces. King County, WA passed a similar local law. In 2012, the state of Oregon passed a law prohibiting the use of tobacco products (including e-cigarettes) in state agency buildings and on state agency grounds. The US Department of transportation banned the use of e-cigarettes in airplanes. Thanks!

What are people worried about?
As far as I see it, people against e-cigarettes have three basic objections:
1) E-cigarettes are inherently bad
2) E-cigarettes are an open doorway to 'real cigarettes' and other tobacco products (which are inherently bad)
3) There is so much money involved, the e-cigarette industry is booming (over $1billion last year, expected to triple this year to over $3 billion), and if there is that much money involved, something bad must be happening.

Well, are they that bad? I already told you what was in them (see box above), and they definitely seem less bad than cigarettes. But do we really know how bad they are? Many anti-smoking groups argue that just because there is not data showing e-cigarettes are safe doesn't mean they are actually safe. Possibly true. Everywhere you look, the powers that be say "this has not been studied". Well, true and not true.

A paper published in 2011 by the Journal of Public Health Policy set out to review the current information on e-cigarettes at the time. Much to the dismay of many health agencies in town, they concluded the following fairly convincing arguments that e-cigarettes may not be so bad after all:

1-There isn't much dangerous in e-cigarettes. As of 2011, more was known about the contents of electronic cigarettes than we know about the chemicals in tobacco cigarettes. As of 2011, sixteen studies had been done characterizing the contents: propylene glycol, glycerin and nicotine. The two agents the FDA has expressed most concern about tobacco-specific nitrosamines (TSNAs)  and diethyelene glycol  (DEG, a toxic agent found in antifreeze and breaks down to toxic agents). TSNAs, one of the main classes of cancer-causing agents known to be in tobacco, were found trace amounts, equivalent to that found in the nicotine patch and orders of magnitude lower than the TSNA levels found in cigarettes (500-1400 fold reduction). In addition, DEG was found in only 1 of 16 studies. Definitely concerning to find DEG at all in the e-cigarettes but hardly an overwhelming problem. Perhaps the presence of these chemicals has been exaggerated?
2-E-cigarettes may actually decrease tobacco craving. There is a small study showing that e-cigarettes may decrease the quantity of cigarettes and aid current smokers in smoking cessation (shhh, manufacturers don't want this word out). Another small study showed evidence that e-cigarettes reduce tobacco cravings.
3-Carcinogens are present in only trace amounts. A direct quote: "Thus far, none of the more than 10,000 chemicals present in tobacco smoke, including over 40 known carcinogens, has been shown to be present in the cartridges or vapor of electronic cigarettes in anything greater than trace quantities."

In addition, most anti-tobacco groups argue that smoking e-cigarettes is a gateway to smoking other cigarettes and tobacco products. This correlation has not been studied (yet), but it's probably a reasonable concern. The e-cigarette industry has come under fire for marketing techniques around e-cigarette flavoring (chocolate and strawberry, seem quite enticing to young people). Additionally, opponents also worry that the mere action of vaping an e-cigarette simulates the habit of smoking (in contrast to nicotine replacement like gum or patch, which is entirely different).

What do I think?
I will take a tripolar stance on this one. All are equally valid:

Opinion #1, My smack down: People should not ever ever ever start smoking or vaping cigarettes of any type. Smoking is gross and addictive and dangerous and does nothing to make humans healthier or happier. 

Opinion #2, The mom in me: I would not want my son to smoke either 'real' or electronic cigarettes. The e-cigarette industry is clearly booming, and I worry that young people are the most vulnerable to be advertised to, enticed to, and sold on their ability to make the world a better place. I think we should all be acutely aware of the power of marketing, and we should stand firm in our message to young people that even e-cigarettes are not sexy.

Opinion #3, The harm reducer: For current smokers, quitting smoking altogether is hands-down the best possible action they can take for their health. However, sometimes it is just not going to happen. Let's be honest. For those long-time smokers who are doing their best to fit into this smokeless world and just cannot seem to find a way to kick the habit, I say, e-cigarettes seem like a pretty reasonable alternative. They are probably safer, definitely cheaper, and for sure better for their lung disease (and their friends and neighbors).

Additional References:


  1. How timely! I just read this about this French study on e-cigarettes yesterday:

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  2. This is a great review on an important topic. I'm still extremely hesitant to endorse e-cigarettes with my patients because so little is known about them. I read one recent study that looked at some of the contents and they found that the quantity of nicotine varied wildly and they even found nicotine in some of the e-cigs that were labeled nicotine free. I just feel like without any FDA regulation and known use of potentially dangerous compounds in them, I've not been given the green light to recommend them. I realize the alternative of smoking is a KNOWN/guaranteed harm, but what if we find out the compounds in e-cigs cause leukemia or something else? I try to tell patients, "you seem motivated, we have a lot of well-studied replacement products or prescriptions that are known to be relatively safe, lets make sure you've tried all of those first."
    yay for the blog.

  3. Michelle, I totally resonate with your hesitancy to recommend something that is understudied. We will know more with time, but the study done in 2011 published in Journal of Public Health really did have a nice table describing all the contents. Here it is:
    Certainly things could have changed since then (and I don't disagree with the benefits of oversight), but I do think we should consider the positive side of actually KNOWING what's in an e-cigarette (as compared to the 10,000+ chemicals in tobacco, may of which are yet to be catagorized and 40 of which are KNOWN carcinogens). What about if a patient uses the JPHP table and picks a brand that has been studied?

  4. Thanks for the blog, I found it very informative. The first time I heard of an e-cig was when my patient, a 76 year old diabetic women, who had been smoking for 40 years, told me that she finally quit. We had worked on a variety of strategies in the past, and she got close with the calendar wean-down approach. When I asked her how she did it, she told me the e-cigarette. I had never heard of them before she mentioned it, and at first I didn't know if it was only a device to hold and puff (without delivering nicotine), or if it did in fact have any nicotine, or any other ingredient for that matter. But all I did know in the office that day was I was so proud of her for quitting. I congratulated her, and tucked away a positive impression of the e-cig. Suffice it to say I have learned a lot since that visit, and most after reading this post. I agree with Dr. Vero, in the best case scenario, I will not recommend them. But, I am thrilled my patient was finally able to quit by using them. And by the way, that was over a year ago, and she is happy and cigarette free!

  5. Thanks for your thoughts, and hooray for your patient for having quit cigarettes! I'll be curious to see if studies are actually done specifically with e-cigarettes for smoking cessation. Seems likely the industry won't want those types of studies because they open themselves up to more medical regulation. We shall see.

  6. Our Costco in Bountiful are selling these now. We do not sell liquor or regular cigarettes. People are very upset about our location selling them now because Bountiful Temple is 5 miles away. Let's see what the sales are and what Costco does!
    I should print this off and put it in our break room!

    1. Super interesting. Interesting that Costco has chosen not to sell alcohol or regular cigarettes. Is it only at your location? Don't most Costcos sell cigarettes?

  7. What about the vapor pens? I have not started research yet, but many young patients of mine in high school and middle school are using them. Sounds like they may not contain nicotine, but the fact that they it 'looks and acts' like a cigarette concerns me. One small step away from more widely available and cheaper cigarettes. Any thoughts?

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