When U.S. Surgeon General Luther Terry released his now famous report on the effects of smoking cigarettes, the consensus — derived from more than 7,000 scientific studies — rippled across the country. It stoked fear in smokers and nonsmokers alike about cigarettes’ likely responsibility for, among other ills, increased rates of lung cancer, heart disease, emphysema, and chronic bronchitis; and it’s credited with paving the way for mandatory health warnings on cigarette packs and a 1970 law banning cigarette ads on TV and radio.
Now, just a few days after the 50th anniversary of that report, countless studies have reaffirmed and expanded on its analyses, and smoking rates have mostly decreased since 1965. But where traditional cigarettes are losing popularity, their newer, cooler, flavored, neon-lit, and more versatile cousin are becoming increasingly in vogue.
According to a report released by the Centers for Disease Control and Prevention (CDC) last February, 20 percent of adult cigarette smokers have tried the electronic versions, a figure that increased 10 percent in one year. About 6 percent of all adults have tried them. More startling for health experts was a survey released in September that showed a doubling in usage among middle school and high school students.
Fans and manufacturers of e-cigarettes say that where traditional cigarettes are bad, e-cigarettes are better. Supporters tout the devices’ smokeless-ness and near-odorless-ness as cures for complaints about secondhand smoke. They say that the liquid is less toxic than tobacco. And most frequently of all, proponents claim e-cigs bridge the gap between smoking cigarettes and not smoking at all.
But the machine’s relative novelty — the first one was invented by a Chinese pharmacist about 10 years ago — and the consequential dearth of scientific study around it is leaving health experts less than sold on their potential benefits and concerned about what decades of study could one day reveal. “Fluid, battery, inhale,” said Dawn Dunn, an administrator for Santa Barbara County Public Health’s Tobacco Prevention Settlement Program. “Never been tried before.”
Warm and Cold Turkey
Although different brands vary slightly, e-cigarettes generally work like this: A heating element warms up the liquid — typically a mix of nicotine, flavorings, and additives — and turns it into a vapor to inhale. Controversy surrounds all of the components.
First, there’s the addictive nicotine, which experts say can pose problems for smokers of traditional cigarettes looking to expand their options, e-cigarette converts trying to quit smoking regular cigarettes, and people — adults and kids alike — turning to the devices for their first, but likely not last, foray into smoking. “Anything you know about nicotine addiction, you can apply,” said Dunn, known as Santa Barbara’s tobacco “czarina.” “Nicotine is a very dependency-producing drug.”
Dr. David Zisman, a pulmonary physician for Sansum Clinic, said he’s seen an increase in the number of patients who smoke e-cigarettes, and he seconded Dunn’s take. “If someone who’s not a smoker gets exposed to nicotine, they could get addicted, and it could be a segue,” he said. “It could also perpetuate the addiction for someone who’s already addicted. Instead of stopping cold turkey and going through withdrawals, they could prolong the addiction.”
For smokers looking to the devices as a means to wean themselves from normal cigarettes, the message touted by health officials is clear: Use caution. Many pointed to a study released in September that compared e-cigarettes to nicotine patches as smoking-cessation methods; the study found no significant differences in success rates. But just because e-cigarettes could help a person transition to no cigarettes at all — partially by mimicking the hand-to-mouth gesture — that doesn’t mean they are the best options, officials said.
“There are much safer alternatives,” said Dr. Takashi Wada, the county’s public health director. “They are regulated. They are monitored and typically under a health provider’s oversight.” Those alternatives can be obtained over-the-counter (nicotine patches, lozenges, and gum) and through a doctor’s prescription (nicotine nasal spray and nasal inhalers, nicotine-replacement-therapy cigarettes, and varenicline, a medication most known by its brand name, Chantix).
“If you’ve already started e-cigarettes as a quitting strategy, I would say to you, use them the way you would use any other nicotine-replacement product,” Dunn said. “Step back your use until you’re not using them at all. If after approximately 16 weeks, you haven’t quit, then you haven’t quit.”
Dr. Richard Belkin and Dr. Jeffrey Kupperman, both of Santa Barbara Pulmonary Consultants, said that they have mentioned e-cigarettes to their patients looking for a way to quit when other methods haven’t worked, although they said they caution that the devices are not FDA-approved and warrant more research. But, Kupperman said, “If they think this is the method that will work for them, I don’t care what they do as long as they quit. Clearly, stopping smoking is the goal they should continue to strive for.”
Nuts and Bolts and Electronics
Along with the liquid nicotine that e-cigarettes normally contain are variable amounts of vegetable glycerin, propylene glycol (a preservative), and polyethylene glycol (used in many pharmaceuticals). But the CDC and other sources have reported that e-cigarettes can also include formaldehyde, lead, and diethylene glycol (which is commonly used in antifreeze), as well as a host of other heavy metals, silicate particles, and animal carcinogens.
Wada said early studies show that e-cigarettes contain fewer hazardous compounds and carcinogens than tobacco, but other concerns abound. There isn’t standardization among brands or even within brands, Zisman said, meaning that the amount of nicotine delivered can vary widely. (For children, swallowing the contents of an e-cigarette cartridge could prove fatal, Zisman said, pointing to a World Health Organization report that stated that a child of about 66 pounds could suffer acute nicotine poisoning by ingesting the contents.)
Because e-cigarettes have only been on the market for a decade, their long-term health effects, separate from possible nicotine addiction, remain a mystery. The sentiment reiterated most by every health official was “more study, more study, more study.” Their short-term consequences, according to information provided by the county’s Tobacco Prevention Settlement Program, can include side effects from throat irritation and dry cough to dizziness, headaches, and nausea.
Although the devices are smokeless and claim to be odorless, non-e-cigarette smokers have reason to worry about the effects, too, as the fallout of secondhand “vaping” can’t be dismissed. “It’s not truly known, but the vapors do contain nicotine and a number of other chemicals,” Zisman said. “I wouldn’t want to be exposed to any of this if I was in a public place.”
So far, secondhand vaping doesn’t seem to be an issue for Santa Barbarans. Several area bars and restaurants reported few complaints when it comes to patrons electronically lighting up. A representative for the Downtown Organization said that the group has received no complaints from business owners or customers about e-cigarettes, and as such, doesn’t have a policy on them.
While there have been select reports nationwide of the devices exploding — singeing tongues, burning lips, and even knocking out teeth — representatives from Cottage Hospital, the Santa Barbara Police Department, and the Sheriff’s Department said they have no way to track such figures, and a representative from Sansum said there have been no reports of e-cigarette-related injuries. Zisman said that the cartridges can spill, but to what extent the liquid poses a risk remains unclear.
As several people interviewed said, “The jury’s still out” on e-cigarettes. That jury isn’t quite ready — and may not be without additional years of research, plus greater regulation and standardization — to wholly condemn the devices or completely let them off the hook, either. “There might be a role as a lesser evil,” Zisman said, “but there are a lot of unknowns, especially for kids. People are being exposed without regulation.”
Dunn summed up her attitude on e-cigarettes with a verbal eye-roll. “There are 5,000 harmful chemicals in a cigarette,” she said. “Cigarettes are the only product that if used as directed will kill you. People are saying this is better than that.”