The truth about e-cigarettes

E-cigarettes are growing in popularity with smokers who are trying to get away from real cigarettes, and their ensuing health risks. But the truth about their safety, and effectiveness in helping people quit smoking, is less clear than manufacturers would have you believe.

Some e-cigarette manufacturers try to market their products by saying that you can smoke them virtually anywhere, unlike regular cigarettes made from tobacco.  That’s not entirely true.

John told me recently that he witnessed his first e-cigarette over the Christmas holiday, and while the device emitted a puff of something, there was no odor. In fact, that “something” might not be entirely safe, as we’ll find out.

Some companies even imply that e-cigarettes are “safer” than smoking tobacco cigarettes.

E-cigarettes 101

E-cigarettes have been around for about 10 years. First developed and marketed in China (not known as a bastion of consumer safety), they were designed to offer a convenient way to enjoy smoking. The e-cigarette is designed to vaporize a liquid (that contains nicotine, flavorants and other substances) and allow it to be inhaled. The liquid can have varying amounts of nicotine. It can also have other substances (flavorants) added (mint, fruit flavors and others.) These flavorants are seen by some as a marketing ploy to get children to start smoking. The liquid may contain other chemicals or impurities, as well.

The basic structure of an e-cigarette, courtesy of the FDA.

The basic structure of an e-cigarette, courtesy of the FDA.

Possible carcinogens, inconsistent nicotine delivery

An Food and Drug Administration analysis of two different e-cigarette liquid bases showed that both tested positive for the presence of nitrosamines. The National Cancer Institute says that some nitrosamines have been shown to cause cancer in laboratory animals and may increase the risk of cancer in humans.

Additionally, the amount of nicotine that was inhaled could vary substantially from the amount of nicotine listed for the cartridge. The amount of nicotine could even vary significantly (by up to 60%) from one puff to the next. And one brand  of e-cigarettes, that claimed to contain no nicotine, in fact contained a very small amount of nicotine. So the e-cigarettes would seem to be inefficient in actually enabling someone to cut down on, or quit, smoking, and could also cause exposure to potential carcinogens.

In a recent study (published as a detailed letter in the JAMA Internal Medicine), the authors state that e-cigarettes are no better than other methods for helping people to quit smoking.

Nicotine is hellishly addictive. Once started, it is difficult to stop. You can ask any smoker who has quit or tried to quit. Most will confirm that quitting is quite a struggle. Quit rates are in the single digits on each attempt that someone makes, even when they use something to help quit, like medications or nicotine patches. (General information on nicotine, addiction and e-cigarettes can be found here.)

Some cities have prohibited e-cigarettes in public spaces, and nicotine-free e-cigs aren’t necessarily nicotine free

As far as being able to smoke e-cigarettes anywhere, that isn’t true.

Some cities, like New York City, Los Angeles, Chicago and Philadelphia have passed laws that prohibit the smoking of e-cigarettes in public places, just as tobacco cigarettes are prohibited. Some businesses, restaurants, schools and other places have banned e-cigarettes. Hospitals generally prohibit them, as well. There is some risk to nearby non-smokers from second-hand smoke.

The FDA has recognized the risks of smoking e-cigarettes and has tried to regulate them as medical devices. When taken to court, the courts have ruled that e-cigarettes are not medical devices. The FDA can, however, regulate them as tobacco products, but that will take longer to do than if they could regulate them as medical devices.  Currently their production is unregulated by the federal government.

Last year, e-cigarette sales in the US were expected to double from the year before, reaching anywhere from $1 billion to $1.8 billion. So there’s a major incentive for manufacturers to delay any action on the FDA’s part as long as possible.

E-cigarettes are not to be sold to persons under 18 years of age. However, some adults with good intentions may buy these for children under 18 thinking that they are not addictive and don’t have any deleterious effects.

An editorial comment in the JAMA Internal Medicine addresses some of the above points.

Reusable e-cigarettes pose their own health risk

One more point: The delivery system is changing, and may now be turning more dangerous.  Reusable e-cigarettes are now on the market, and the liquid nicotine, that you refill the e-cigarette with yourself, is highly toxic if it comes into contact with your skin.  The NYT delved into this in more detail just a few days ago.

E-cigarette via Shutterstock

E-cigarette via Shutterstock

These “e-liquids,” the key ingredients in e-cigarettes, are powerful neurotoxins. Tiny amounts, whether ingested or absorbed through the skin, can cause vomiting and seizures and even be lethal. A teaspoon of even highly diluted e-liquid can kill a small child.

But, like e-cigarettes, e-liquids are not regulated by federal authorities. They are mixed on factory floors and in the back rooms of shops, and sold legally in stores and online in small bottles that are kept casually around the house for regular refilling of e-cigarettes.

So, is there any value in using e-cigarettes to attempt to quit smoking? There might be a slight advantage over the nicotine patches. But, as described above, the difference isn’t statistically significant, and those nicotine patches are regulated by the FDA — e-cigarettes have not been.

Are e-cigarettes dangerous? Those containing nicotine can be addictive. They may also contain other substances that may be carcinogenic. And keeping the refill vial around your house, and using it, could pose serious health risks as well.

Is it a good idea to stay away from products containing nicotine? Yes.  Are e-cigarettes such products? Yes.

Here’s a recent CNN segment on e-cigarettes, so you can see one in action:


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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