The conundrum, as I see it, is threefold. The first step is to determine if vaping is a significant alternative to smoking cessation. The second is to determine if any components of vaping (nicotine, propylene glycol, or combustion) are safe for humans. Lastly, we must establish how to regulate e-cigarettes, given scientific uncertainty as to their therapeutic effects.4
In 2013, Palazzolo did a literature review of 66 articles related to e-cigarettes and vaping. He found that, when compared to the effects of smoking, vaping could be a substitute for smoking and a conceivable means for smoking reduction. It was unclear, however, if vaping could reduce nicotine addiction. He reported that the effects of vaping on human health are questionable, due to the extreme scarcity of empiric research.5
Although there has been a paucity of research on this topic, a study by Goniewicz and colleagues reports on the toxicants emitted by tobacco cigarettes and e-cigarettes.6 Their results indicate that e-cigarettes emit fewer toxicants than traditional tobacco cigarettes (formaldehyde, 0.20-5.61 µg and 1.6-52 µg, respectively; acetaldehyde, 0.11-1.36 µg and 52-140 µg).7 Despite this evidence, more studies need to be done on the effects of propylene glycol inhalation to determine the safety of e-cigarettes.
Another concern has been the lack of an age restriction on e-cigarettes and their growing popularity among grade and high school students.E-cigarette use doubled among US middle and high school students from 2011 to 2012, resulting in an estimated 1.78 million students who have used e-cigarettes as of 2012. There is serious concern about the possible harmful impact of nicotine on adolescent brain development,as well as the risk for nicotine addiction.8
Amid these growing questions and concerns, the FDA issued a warning that e-cigarettes may be as bad as the real thing and has recommended against their use.9 Just last month, the agency finalized a regulation on all tobacco products, including vaporizers, vape pens, hookah pens, e-cigs, and e-pipes. They will now regulate the manufacturing, import, packaging, labeling, and distribution of e-cigarettes to ensure that ingredients are assessed and determined to be safe for human use.FDA Commissioner Robert M. Califf, MD, said, “We must do our job under the Tobacco Control Act to reduce the harms caused by tobacco. That includes ensuring that consumers have the information they need to make informed decisions about tobacco use and making sure that new tobacco products for purchase come under comprehensive FDA review.”10,11
Well, is it just a bunch of smoke, or are the new regulations and health warnings about e-cigarettes long overdue? I would love to hear your experiences and additional advice for our colleagues and patients regarding the use of e-cigarettes and vaping. You can reach me at PAEditor@frontlinemedcom.com.
References
1. Jerry JM, Collins GB, Streem D. E-cigarettes: safe to recommend to patients? Cleve Clin J Med. 2015;82(8):521-526.
2. McMillen RC, Gottlieb MA, Shaefer RMW, et al. Trends in electronic cigarette use among US adults: use is increasing in both smokers and nonsmokers. Nicotine Tob Res. 2015;17:1195-1202.
3. National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. www.ncbi.nlm.nih.gov/pubmed/24455788. Accessed May 10, 2016.
4. Gostin LO, Glasner AY. E-cigarettes, vaping, and youth. JAMA. 2014;312(6):595-596.
5. Palazzolo DL. Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review. Front Public Health. 2013;1(56):1-20.
6. Goniewicz ML, Hajek P, McRobbie H. Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications. Addiction. 2014;109(3):500-507.
7. Arnold C. Vaping and health: what do we know about e-cigarettes? Environ Health Perspect. 2014;122(9):A244-A249. http://ehp.niehs.nih.gov/122-a244. Accessed May 10, 2016.
8. Electronic cigarette use among middle and high school students. Medscape. September 6, 2013. www.medscape.com/viewarticle/811008. Accessed May 10, 2016.
9. FDA: E-cigarettes may be as bad as real thing. NBC Nightly News. July 22, 2015. www.nbcnews.com/video/nightly-news/32091534#32091534. Accessed May 10, 2016.
10. Caudle J. Why we need new rules on e-cigs. CNN. May 6, 2016. www.cnn.com/2016/05/06/opinions/fda-electronic-cigarettes-caudle. Accessed May 10, 2016.
11. FDA. FDA takes significant steps to protect Americans from dangers of tobacco through new regulation [news release]. May 5, 2016. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm499234.htm. Accessed May 10, 2016.