UPDATE

Electronic Cigarette: Some basics & facts

An electronic cigarette (e-cig or e-cigarette), personal vaporizer (PV) or electronic nicotine delivery system (ENDS) is a battery-powered vaporizer which simulates tobacco smoking by producing an aerosol that resembles smoke. It uses a heating element, ‘atomizerthat vaporizes a liquid solution, ‘e-liquid’. E-liquids contain a mixture of propylene glycol, vegetable glycerin, nicotine, and flavorings, while some release a flavored vapor without nicotine.

Currently marketed e-cigarette devices arose from an invention made in China in 2003 and devices are predominantly manufactured in China. E-cigarette brands have been rapidly increasing using aggressive marketing as those used to popularize cigarettes in the 1950s and 1960s.

Because of the possible relationship to tobacco laws and medical drug policies, electronic cigarette legislation and public health investigations are currently pending and are being debated in many countries. The European Parliament passed regulations in February 2014 requiring standardization of liquids and personal vaporizers, disclosure of ingredients, and child- and tamper-proofing of liquid containers; the Food and Drug Administration published proposed regulations in April 2014 along similar lines.

Construction

Disassembled cigarette-styled electronic cigarette. A. LED light cover
B. Battery (also houses circuitry)
C. Atomizer (heating element)
D. Cartridge (mouthpiece)

Usage statistics

Electronic cigarette sales increased from 50,000 in 2008 to 3.5 million in 2012. As of 2011, in US, one in five adults who smoke, have tried e-cigarettes.

In a UK survey in 2013 of more than 12,000 adults, 11% of regular smokers had usede-cigarettesand 24% had used them in the past. 1% had tried them with no evidence of continued use. In 2014 the number of people who had ever smoked, 52% reported using e-cigarettes.

Among grade 6-12 students in USA, those who have ever (at least once) used the product increased from 3.3% in 2011 to 6.8% in 2012.Those currently using e-cigarettesincreased from 0.6% to 1.1%. Over the same period the percentage of grade 6 to 12 students who regularly smoke tobacco cigarettes fell from 7.5% to 6.7%.10% of students who have used e-cigarettes at least once have never smoked.A 2013 UK survey by Action on Smoking and Health found that among non-smokers under 18, 1% reported having tried e-cigarettes "once or twice," and no evidence of continued use. ASH concluded that among children who have heard of e-cigarettes, sustained use is rare and confined to children who smoke or have smoked.

Most people who use e-cigaretteshave a history of smoking cigarettes while some young people who have never smoked cigarettes have tried e-cigarettesat least once. The frequency of use has increased with up to 10% of American high school students having ever used them as of 2012 and around 3.4% of American adults as of 2011.The majority of e-cigarette users continue to smoke traditional cigarettes.

A February 2014 survey by the French Monitoring Centre for Drugs and Drug Addiction of 2052 individuals estimated that between 7.7 and 9.2 million individuals have experimented with using e- cigarettes, with between 1.1 and 1.9 million using on a daily basis. 67% of tobacco smokers in the survey used e-cigarettesto reduce or quit tobacco smoking. 9% of those who experimented with e-cigaretteshad never smoked tobacco. Of the 1.2% that had recently stopped tobacco smoking at the time of the survey, 84% (or 1% of the population surveyed) credited e-cigarettesfor stopping tobacco use.

History

The earliest e-cigarette can be traced to Herbert A. Gilbert, who in 1963 patented a device described as "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air". This device heated the nicotine solution and produced steam. It was never commercialized.

Hon Lik, a Chinese pharmacist, is credited with the invention of the e-cigarette in 2003.

Legal status

The emerging phenomenon of e-cigaretteshas raised concerns among the health community, pharmaceutical industry, health regulators and state governments. Some jurisdictions are now prohibiting or regulating the use of e-cigarettes in public spaces.

Because of the relative new technology and the possible relationship to tobacco laws and medical drug policies, e-cigarette legislation and public health investigations are currently pending in many countries. Current regulations vary widely, from regions with no regulations to others banning the devices entirely.

In February 2014 the European Parliament passed regulations requiring standardization and quality control for liquids and vaporizers, disclosure of ingredients in liquids, and child-proofing and tamper-proofing for liquid packaging. In April 2014 the US FDA published proposed regulations for e-cigarettes along similar lines.In March 2014 Western Australia banned sale of e-cigarettes.

Health effects

Smoking cessation

In July 2014, The World Health Organization (WHO) released a report which found insufficient evidence to determine an effect of e-cigaretteson the ability to quit smoking. While not approved by any government they may be a reasonable option in those who have not had success with other methods. This is a change from the position of WHO in July 2013 which stated that the effectiveness of e-cigarettesin aiding smoking cessation had not been demonstrated and recommend that "consumers should be strongly advised not to use" e-cigarettesunless a reputable national regulatory body has found them safe and effective. The US Government smoking cessation site, smokefree.gov stated the efficacy of e-cigarettesin aiding smoking cessation has not been demonstrated and don’t recommend them to use.

The concept of harm reduction has been debated in the public health approach of tobacco control. A 2011 review article states how e-cigarettesmay aid in smoking cessation and may likely be more effective than traditional pharmacotherapy, as the physical stimuli of holding and puffing on the electronic cigarette may better reduce short-term cravings. The review found no studies that directly measured the effectiveness of e-cigarettesin smoking cessation, and examined two published studies that indirectly consider the issue by measuring the effect of the product on cravings and other short-term indicators. A 2014 review asserted how e-cigarettesmay be a reasonable substitute for cigarette smoking. The review also states that even individuals that did not intend to quit smoking before being introduced to e-cigarettes may subsequently do so. Another 2014 review concluded that the benefit with respect to helping people quit smoking was uncertain.

The American Association of Public Health Physicians (AAPHP) suggests those who are unwilling to quit tobacco smoking or unable to quit with medical advice and pharmaceutical methods should consider other nicotine containing products such as e-cigarettesand chewing tobacco for long term use instead of smoking.

The British Medical Association (BMA) reported in 2013 that there was a possibility for smoking cessation benefits, but had concerns that e-cigarettes are less regulated than nicotine replacement therapy (NRT), and that there was no peer reviewed evidence concerning their safety or efficacy. Recommendations point to a "strong regulatory framework" for e-cigarette distribution in order to ensure the safety, quality, and that marketing and sales are restricted to adults. The BMA encourages health professionals to recommend conventional nicotine replacement therapies, but for patients unwilling to use or continue using such methods, health professionals may present e-cigarettes as a lower-risk option than tobacco smoking.

A report by Public Health England concluded that there is large potential for health benefits when switching from tobacco use to other nicotine delivery devices such as e-cigarettes, but realizing the full potential requires regulation and monitoring to minimize possible risks.

A 2012 review found electronic systems appear to generally deliver less nicotine than smoking, raising the question of whether they can effectively substitute for tobacco smoking over a long-term period.

A 2013 randomized controlled trial found no difference in smoking cessation rates between e-cigarettes with nicotine, e-cigarettes without nicotine and traditional NRT patches.[22]There are some non-controlled studies which have reported possible benefit.

E-cigaretteswere not regularly associated with trying to quit tobacco among young people. Adults most often used e-cigarettesas a replacement for tobacco, although not invariably to quit. The majority of e-cigarette users continue to smoke traditional cigarettes. The majority of youth using e-cigarettes are dual users, though some youth who used an e-cigarette have never tried a traditional cigarette. Although some people have a desire to quit smoking by using e-cigarettes, other common explanations for the use of these products are to reduce harm from smoking, and to cut back on traditional cigarettes, which may reinforce delaying or deterring to quit smoking.

Safety

The risks of e-cigarette use are uncertain. This is due to there being little data regarding their health effects and to the variability of vaporizers, liquid ingredients and in their concentration and quality, and therefore variability of the contents of aerosol delivered to the user. However, some evidence suggests e-cigarettes may be safer than smoking tobacco products and possibly as safe as other nicotine replacement products but there is insufficient data to draw conclusions. Switching from smoking tobacco to using e-cigarettes may result in reduced exposure to nicotine and reduced potential risk of disease from smoking.

 

Chart showing various toxicants as measured in cigarette and e-cigarette smoke.

A preliminary analysis of e-cigarette cartridges by the US Food and Drug Administration (FDA) in 2009 identified that some contain tobacco-specific nitrosamines (TSNAs), known cancer-causing agents. The amounts of TSNAs present were on par with existing NRT products like nicotine gum and inhalers. The FDA's analysis also detected diethylene glycol, a poisonous and hygroscopic liquid, in a single cartridge manufactured by Smoking Everywhere and nicotine in one cartridge claimed to be nicotine-free. Diethylene glycol was found in a cartridge tested in 2009 by the FDA, but in 2011 researchers reviewed the data and noted that 15 other studies had failed to find any evidence of this chemical in e-cigarettes. Further concerns were raised over inconsistent amounts of nicotine delivered when drawing on the device. In some e-cigarettes, "Tobacco-specific impurities suspected of being harmful to humans – anabasine, myosmine, and β-nicotyrine – were detected in a majority of the samples tested. The UK National Health Service noted that the toxic chemicals found by the FDA were at levels one-thousandth that of cigarette smoke and while there is no certainty that these small traces are harmless, initial test results are reassuring. While propylene glycol and other chemicals commonly used as solvents or carrier compounds in e-cigarettes liquids are generally recognized as safe, they have not been used before in vaporized form over long periods of time. The risks, especially to the lungs, are not fully understood and are of concern to public health authorities and some reviewers. Some reviewers have noted that while there is variability in the ingredients and concentrations of ingredients in e-cigarette liquids, tobacco smoke contains thousands of chemicals, most of which are not understood and many of which are known to be harmful.

A report by WHO from August 2014 cautioned about potential risks of using electronic cigarettes. Passive exposure was also mentioned as a concern with the report, indicating that current evidence is insufficient to determine whether the levels of exhaled aerosol are safe to involuntarily exposed bystanders. Rare major injuries have occurred from battery malfunctions such as explosions and fires. Less serious adverse events of e-cigarette use included throat and mouth inflammation, cough, nausea, and vomiting. Liquids used with e-cigarettes also pose a risk if they are ingested or if the skin is exposed to them, especially for children. In the US, the number of calls to poison control centers associated with e-cigarette liquid rose from one per month in September 2010 to 215 per month in February 2014; the proportion related to e-cigarettes jumped from 0.3 percent in September 2010 to 41.7 percent in February 2014. More than half (51.1 percent) of the calls to poison centers due to e-cigarettes involved children under 5 years old.

Second hand vapor

Generally e-cigarette aerosol has notably fewer toxicants than cigarette smoke (other than particulates) and is likely to pose less harm to others. Studies found e-cigarettes emissions put into the air known carcinogens, ultrafine particles, and heavy metals. Studies funded by the e-cigarette industry and e-cigarette proponents have concluded the levels are not of significant health concern for human exposures.

Addiction

It is unclear whether using e-cigarettes will decrease or increase overall nicotine addiction. A number of organizations including, the Centers for Disease Control and Prevention, the International Union Against Tuberculosis and Lung Disease, the American Academy of Pediatrics and the Food and Drug Administration, have concerns that e-cigarettes might increase addiction to and use of nicotine and tobacco products in children. The World Health Organization raised concern of addiction for nonsmokers from their use in July 2013.There is no evidence that they are used regularly by those who have never smoked. However CDC finds rising number of youth have used e-cigaretteswho have never smoked. Around 1% of adults in the UK who don't smoke tobacco products have tried e-cigarettes; and less than 0.3% of never-smoking teens in Scotland. In the US, survey results showed that, among youth who never smoked, 0.9% have tried an e-cigarette, and 0.3% have used one in the last 30 days.

-Alok Gupta, Jaipur, docalok@hotmail.com