Although much controversy surrounds each, with almost no regulations, electronic cigarettes (e-cigarettes) and personal vaporizers have gained in popularity over the last several years. Some use these devices to abstain from regular cigarette use, some consider them to be healthier options for themselves and those around them.
Both the e-cigarette and the vaporizer function in much the same way however, the e-cigarette has more of a reputation for being associated with nicotine than do vaporizers although vaporizers can have nicotine in them, as well.
E-cigarettes are designed to look like cigarettes with their thin and cylindrical shape. Their sizes are also smaller than the ordinary vaporizer pens. There are e-cigarette models that have LED lights at the bottom tip that glow every time the user takes a draw from the device.
E-cigarettes come in three basic parts: the cartridge or a cartomizer the battery, and the mouthpiece. The cartridge of the typical e-cigarette contains and vaporizes the liquid material called e-juice, which contain the nicotine or other flavorings. To provide that thick cloud of vapor, e-juices usually contain propylene glycol, a vegetable based material that transforms into visible vapor when heated.
These devices are meant to forgo the tobacco. The user inhales an aerosol or vapor instead of cigarette smoke. The vapor is typically released by a heating element that atomizes a liquid solution known as e-liquid. The user activates the device by taking a puff or pressing a button. Most are reusable but there are also disposable versions.
While e-cigarettes and vaporizers are often promoted as safer alternatives to traditional cigarettes, which deliver nicotine by burning tobacco, little is actually known about the health risks of using these devices. As mentioned the e-liquids used usually contain a mix of propylene glycol, glycerin, nicotine, and flavorings. Some e-liquids may contain ingredients such as cannabis or tobacco products. E-cigarettes create a vapor whose composition varies across and within manufacturers. The vapor can contain small amounts of toxins, including traces of heavy metals detected at levels permissible in inhalation medicines, and some potentially harmful chemicals not found in tobacco smoke at levels permissible by workplace safety standards. However, chemicals may exceed the more stringent safety limits which are relevant to the population as a whole. High aldehyde levels, which have been generated in laboratory settings by researchers overheating e-liquid, can cause a highly aversive acrid taste that users would not like to subject themselves to.
The earliest e-cigarette can be traced to American Herbert A. Gilbert, who in 1963 patented “a smokeless non-tobacco cigarette that replaced burning tobacco with a heated, moist, flavored compound. This device produced flavored steam without nicotine. The patent was granted in 1965. Gilbert’s invention was ahead of its time. There were prototypes, but they received little attention and were never commercialized because smoking was still fashionable at that time. Gilbert said that today’s electric cigarettes follow the basic design set forth in his original patent. The modern e-cigarette arose from a 2003 invention by Chinese pharmacist Hon Lik, and as of 2015 most e-cigarettes were made in China. The primary parts of a typical e-cigarette includes a mouthpiece, a cartridge (tank), a heating element/atomizer, a microprocessor, a battery, and possibly a LED light on the end. When the user activates a pressure sensor by inhaling, the heating element atomizes the liquid solution; the e-liquid reaches a temperature of roughly 100-250 °C within a chamber to create an aerosolized vapor. The user inhales the aerosol, commonly called vapor, rather than cigarette smoke. The aerosol provides a flavor and feel similar to tobacco smoking. As the industry continues to evolve, new products are developed and brought to market, however regulations are not up to speed. First generation e-cigarettes tend to look like tobacco cigarettes.
The look of these devices has changed over the years as well. A traditional cigarette is smooth and light whereas e-cigarettes and vaporizers are rigid and heavier. Second generation devices are larger overall and look less like tobacco cigarettes. Third generation devices include mechanical mods and variable voltage devices. The fourth generation includes Sub ohm tanks and temperature control devices. The power source is typically a rechargeable lithium-ion battery.
Since their introduction to the market in 2004, global usage of e-cigarettes has risen rapidly and by 2015 there were several million users globally. As of 2014, 12.6% of adults in the US had used an e-cigarette at least once and approximately 3.7% were still using them. However, growth in the US has reportedly slowed in 2015 and looks to continue to decline in 2016. The reason for this decline is unclear. Some researcher suggest it may be as simple as the newness of these devices is wearing off. Surveys in 2010 and 2011 suggests that adults with higher incomes may have been more likely to have heard of e-cigarettes, but those with lower incomes may have been more likely to try them. In addition, most users had a history of smoking regular cigarettes, while results by race were mixed. At least 52% of current or former smokers have experimented with e-cigarette. Of those smokers who experimented with e-cigarettes about 15% became regular users. Everyday use is common among e-cigarette users and regular e-cigarette users generally continue smoking traditional cigarettes. Many say e-cigarettes help them cut down or quit smoking. The highest percentage of e-cigarette users are middle-aged men who typically use to help them reduce their use of traditional cigarettes. Non-smokers and former smokers who had quit more than four years earlier were unlikely to be current users.
Researchers indicate that one of the main reasons people use is that they believe it will help them to reduce tobacco use. The number of women experimenting with e-cigarettes is increasing. Again, the basic belief is that it will help them stop smoking and that they can use in areas where smoking is banned. Everyday use of e-cigarettes is less common with women than men; however, they generally continue to use traditional cigarettes. There is also wide concern for men, women and youth that vaping may be a “gateway” to smoking. Some young people who have tried e-cigarettes have never smoked tobacco. This indicates that e-cigarettes can be a starting point for smoking. On the other hand, there is no evidence that e-cigarettes increase teen tobacco smoking. There may even be tentative evidence that e-cigarettes divert youth away from cigarettes.
YOUTH INVOLVEMENT WITH E-CIGARETTES/OTHER CONSIDERATIONS
The recent Monitoring the Future survey of students’ drug use and attitudes revealed that adolescents have taken to e-cigarettes in a big way. When asked in early 2014, 17.1 percent of high school seniors and 16.2 percent of 10th graders reported using e-cigarettes in the previous month. We are still wrestling with whether or not e-cigarettes pose a danger, but their popularity among youth combined with our past experiences with tobacco and other addictive substances demands that we urge caution around this product.
E-cigarettes are being aggressively marketed as glamorous devices that empower users (both youth and adult)—by giving them the freedom to use in public places where cigarette smoking is banned. Even though sellers are careful not to make explicit health claims, another part of the “freedom” being sold is, implicitly, the freedom to enjoy the smoking experience without fear of long-term health consequences such as death from cancer or heart disease. This is premature and a potentially misleading statement considering different ingredients can be used in different devices. Those who remember the history of early cigarette marketing in America will experience a sense of “here we go again”. Freedom was the concept used in the 1920s and 1930s to market cigarettes to women, a vast then-untapped market for what had previously been primarily a male experience. Cigarette smoking was sold to women as an image to help them feel liberated and empowered.
Although the vapor produced by e-cigarettes contains no tar—the main cause of lung cancer—it may contain other potentially harmful chemicals. There are currently no regulatory controls over these products, most are made in China, and testing of some products’ vapor has shown toxic metals, possibly produced by the vaporizing mechanism itself.
E-cigarette fluids vary widely in their nicotine concentrations, and the amount a user is exposed to depends on a range of factors (like how many puffs they take, how deeply they inhale, and how long they hold it), but there is clearly a potential for these products to promote addiction—especially when users start in their teens. Recent research in rodents suggests nicotine may even promote addictive behavior by altering gene expression; consequently, it could serve as a gateway to abuse of other substances. Apart from the possible dangers of nicotine, e-cigarette use is normalizing and even glamorizing smoking behavior, which had been successfully stigmatized through public-health campaigns of the past decades. It would be tragic if e-cigarettes re-opened the door to teen tobacco use, which has been slowly but surely declining since the late 1990’s.
A recent study showed that students who have used e-cigarettes are more likely than others to start smoking traditional cigarettes. Also, testing of some e-cigarette products found the vapor to contain known carcinogens and toxic chemicals (such as formaldehyde and acetaldehyde). The health consequences of repeated exposure to these chemicals are not yet clear.
SAFETY AND HEALTH
Are e-cigarettes safer than regular cigarettes? Unfortunately, this question is difficult to answer because of complexity and the lack of data. There have been limited studies and trials to date to help us understand the risks of e-cigarette use. This is becoming a high priority as e-cigarettes are becoming entrenched into our society and history proves that once a product is accepted it is very difficult to control or eliminate.
E-cigarettes typically contain less nicotine than tobacco cigarettes; however, this trait is subject to change when e-cigarettes users demand a higher nicotine content. As noted previously, e-cigarettes are not yet subject to regulations similar to those imposed on tobacco products. Researchers expect to see regulations in the near future that will impose minimum age requirement and other controls for purchasers. Some states have already banned sale of e-cigarettes to minors, but they can get around that by ordering online. Their easy availability, in addition to their wide array of cartridge flavors (such as mint and fruit flavors), make them particularly appealing to adolescence.
There are also other concerns with e-cigarettes:
- Unknown product that has been allowed to dominate the market place (around the world);
- May lead to use of harmful products (including tobacco and other addictive substances) by altering the content of e-liquids.
Speculation is that a manufacturer or user can modify the e-liquid to add almost any addictive substance—-this represent s a very risky and unpredictable situation.
Given the “unknowns” associated with e-cigarettes and vaporizers we must make an accelerated effort to evaluate this product to educate current and future users.
Smoking cigarettes remains the leading cause of preventable sickness and mortality and e-cigarettes and vaporizers could potentially help reduce this problem (if they are proven effective and safe and help the user to reduce tobacco use). Smoking tobacco is responsible for over 400,000 deaths in the United States each year. The worst health consequences associated with smoking (e.g., cancer and heart disease) are linked to inhalation of the tar and other chemicals produced by tobacco combustion. With the e-cigarettes not containing tar there is potential here. As e-cigarettes are designed to simulate the act of tobacco smoking by producing an appealingly flavored aerosol that looks and feels like tobacco smoke and delivers nicotine but with less of the toxic chemicals produced by burning tobacco leaves these could prove to be a safer, less toxic alternative to conventional cigarettes. However much is yet to be learned on the long term effects and “better” does not necessarily mean “safe”.
Another worry is the refillable cartridges used by some e-cigarettes. Users may expose themselves to potentially toxic levels of nicotine when refilling them. Cartridges could also be filled with substances other than nicotine, thus possibly serving as a new and potentially dangerous way to deliver other drugs.
IMPACT ON TEENS (The following comments are from NIDA director Nora Volkow)
She concludes that teens using e-cigarettes are more likely to start smoking tobacco. In the US, the recent fall in smoking has accompanied a rapid growth in the use of alternative nicotine products among young people and young adults. In the US, vaping among young people exceeded smoking in 2014. As of 2014, up to 13% of American high school students have used them. Between 2013 and 2014, vaping among students tripled. In 2013 the Centers for Disease Control and Prevention (CDC) estimated that between 2011 and 2012 around 160,000 students who had tried vaping had never smoked. E-cigarette use among never-smoking youth in the US correlates with elevated desires to use traditional cigarettes. Teenagers who had used an e-cigarette were more inclined to become smokers than those who had not. The majority of young people who vape also smoke. A 2010-2011 survey of students at two US high schools found that vapers were more likely to use hookah and blunts than smokers. Among grade 6 to 12 students in the US, the proportion who have tried them rose from 3.3% in 2011 to 6.8% in 2012. Those still vaping over the last month rose from 1.1% to 2.1% and dual use rose from 0.8% to 1.6%. Over the same period the proportion of grade 6 to 12 students who regularly smoke tobacco fell from 7.5% to 6.7%.
MOTIVATION TO EXPERIMENT
Researchers have concluded that many adult vapers believe usage is healthier than smoking for themselves and bystanders, some are concerned about the possible adverse health effects. Others use them to circumvent smoke-free laws and policies, or to cut back on cigarette smoking. Not having odor from smoke on clothes on some occasions prompted interest in or use of e-cigarettes. E-cigarette users have contradictory views about using them to get around smoking bans. Users sometimes use e-cigarettes without nicotine around friends for the convenience. Non-smoking adults tried e-cigarettes due to curiosity, because a relative was using them, or because they were given an e-cigarette. College students often vape for experimentation. Expensive marketing aimed at smokers suggests e-cigarettes are “newer, healthier, cheaper and easier to use in smoke-free situations, all reasons that e-cigarette users claim motivate their use”. Exposure to e-cigarette advertising influenced people to try them. The majority of committed e-cigarette users interviewed at an e-cigarette convention found them cheaper than traditional cigarettes. Colorful e-cigarettes have a special appeal to younger users. Also, candy, fruit, coffee and other flavorings make them more appealing.
Some users stopped vaping due to issues with the devices. Dissatisfaction and concerns over safety can discourage ongoing e-cigarette use. Some surveys found that a small percentage of users’ motives were to avoid smoking bans, but other surveys found that over 40% of users said they used the device for this reason. The health and lifestyle appeal may also encourage young non-smokers to use e-cigarettes, as they may perceive that trying e-cigarettes is less risky and more socially appealing. This may soften the negative beliefs or concerns about nicotine addiction. Adolescent experimenting with e-cigarettes may be sensation seeking behavior, and is not likely to be associated with tobacco reduction or quitting smoking. Young people may view e-cigarettes as a symbol of rebellion. Originally, the main reasons young people experimented with e-cigarettes were due to curiosity and peer influences. Some advocates say there is concern that e-cigarettes could be appealing to youth due to their high-tech design and accessibility online. At least one advocacy group claims that candy and fruit flavors e-cigarettes are designed to appeal to young people.
Users may begin by using a disposable e-cigarette, and e-cigarette users often start with e-cigarettes resembling normal cigarettes, eventually moving to a later-generation device. Most later-generation e-cigarette users shifted to their present device to get a “more satisfying hit”, and users may adjust their devices to provide more vapor for better “throat hits”.
Electronic cigarettes may be used with other substances and cartridges can potentially be filled with substances other than nicotine, thus serving as a new and potentially dangerous way to deliver other drugs, for example psychoactive or psychotropic drugs such as THC.
The emergence of e-cigarettes has given cannabis smokers a new method of inhaling cannabinoids; however, they differ from traditional marijuana cigarettes in several respects. It is assumed that vaporizing cannabinoids at lower temperatures is safer because it produces smaller amounts of toxic substances than the hot combustion of a marijuana cigarette. Recreational cannabis users can discretely “vape” deodorized cannabis extracts with minimal annoyance to the people around them and less chance of detection, known as “stealth vaping”. While cannabis is not readily soluble in the liquid used recipes containing synthetic cannabinoids which are soluble may be found on the Internet. Cannabinoid-enriched e-liquids require lengthy, complex processing, some being readily present on the Internet despite lack of quality control, expiry date, conditions of preservation, or any toxicological and clinical assessment.
The available research on the safety and efficacy of e-cigarette use for smoking cessation is limited and the evidence is contradictory. Some medical authorities recommend that e-cigarettes have a role in smoking cessation, and others disagree. Views of e-cigarettes’ role range from on the one hand Public Health England, who recommend that stop-smoking practitioners should: (1) advise people who want to quit to try e-cigarettes if they are not succeeding with conventional nicotine replacement therapy (NRT); and (2) advise people who cannot or do not want to quit to switch to e-cigarettes to reduce smoking-related disease, on the other hand, the United States Preventive Services Task Force advised only use of conventional NRT products in smoking cessation and found insufficient evidence to recommend e-cigarettes for this purpose. It must be re-emphasized that e-cigarettes have not been subject to the same efficacy testing as nicotine products. Several authorities, including the World Health Organization, take the view that there is not enough evidence to recommend e-cigarettes for quitting smoking in adults, and there are studies showing a decline in smoking cessation among dual users. A 2014 review found that e-cigarettes do not seem to improve cessation rates compared to regulate nicotine replacement products, and a trial found 29% of e-cigarette users were still vaping at 6 months, but only 8% of patch users still wore patches at 6 months.
In 2015, the United States Preventive Services Task Force concluded there is insufficient evidence to recommend e-cigarettes for smoking cessation, and recommended clinicians instead recommend more proven smoking cessation aids. In 2015, the American Academy of Pediatrics strongly recommended against using e-cigarettes to quit smoking, stating that for adolescent’s e-cigarettes are not effective in treating tobacco dependence. In August 2014, the American Heart Association released a policy statement concluding that while e-cigarette aerosol is much less toxic then cigarette smoke there is insufficient evidence for clinicians to counsel smokers to use them as a primary cessation aid. If a patient failed initial treatment or refuses to use cessation medication, and wishes to use e-cigarettes to quit, it is reasonable to support the attempt after informing them of risks and uncertainties. In 2014, the US FDA said “E-cigarettes have not been fully studied, so consumers currently don’t know: 1) the potential risks of e-cigarettes when used as intended; 2, how much nicotine or other potentially harmful chemicals are being inhaled during use; and 3) whether there are any benefits associated with using these products. Additionally, it is not known whether e-cigarettes may lead young people to try conventional cigarettes, which are known to be a health hazard.
Harm reduction is the replacement of tobacco cigarettes with lower risk products to reduce tobacco related death and disease. It has been controversial out of fear that tobacco companies cannot be trusted to produce and market products that will reduce the risks associated with tobacco use. E-cigarettes can reduce smokers’ exposure to carcinogens and other toxic substances found in tobacco. Tobacco smoke contains 100 known carcinogens, and 900 potentially cancer causing chemicals, none of which has been found in more than trace quantities in the cartridges or aerosol of e-cigarettes. According to a 2011 review, while e-cigarettes cannot be considered “safe” because there is no safe level for carcinogens, they are doubtless safer than tobacco cigarettes. However, some reviews have concluded that the benefits and the health risks of e-cigarettes are uncertain and the long-term health effects are unknown. A core concern is that smokers who could have quit completely will develop an alternative nicotine addiction instead. A 2014 review stated that promotion of vaping as a harm reduction aid is premature but in an effort to decrease tobacco related death and disease, e-cigarettes have a potential to be part of the harm reduction strategy. Another review found that compared with cigarettes, e-cigarettes are likely to be much less harmful to users or bystanders.
A key ingredient in e-liquids is nicotine which is a highly addictive substance. It induces strong effects on the brain, which lead to considerable changes in the brain’s physiology such as stimulation in regions of the cortex associated with reward, pleasure and reducing anxiety. When nicotine intake stops, withdrawal symptoms include cravings for nicotine, anger/irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger or weight gain, and difficulty concentrating. It is not clear whether e-cigarette use will decrease or increase overall nicotine addiction, but the nicotine content in e-cigarettes appears to be adequate to sustain nicotine dependence.
The World Health Organization has raised concern about addiction for non-smokers and the National Institute on Drug Abuse said e-cigarettes could maintain nicotine addiction in those who are attempting to quit. The limited available data suggests that the likelihood of abuse from e-cigarettes is smaller than traditional cigarettes. A 2014 systematic review found that the concerns that e-cigarettes could lead non-smokers to start smoking are unsubstantiated. No long-term studies have been done on the effectiveness of e-cigarettes in treating tobacco addiction, but some evidence suggests that dual use of e-cigarettes and traditional cigarettes may be associated with greater nicotine dependence. Many studies have focused on young people in particular, since youthful experimentation with e-cigarettes could lead to addiction. A significant numbers of teenagers who have never smoked tobacco have experimented with e-cigarettes. The degree to which teens are using e-cigarettes in ways the manufacturers did not intend, such as increasing the nicotine delivery, is unknown.
Researchers recommend a similar treatment approach for cessation of e-cigarettes as is used for stopping regular cigarette use. Cessation for regular use has been treated via two primary approaches; the first being the pharmacological and the second being a behaviorist.
The pharmacological approach includes methods of delivering nicotine to the system without smoking, on the theory that the user will gradually wean off. These nicotine replacement therapies include the nicotine patch, nicotine gum, nicotine nasal spray and the nicotine inhaler. Obviously, e-cigarettes fit into this class if and when it is verified to be effective and safe. Recent studies show that nicotine replacement therapies can help smokers quit. People using aids are 70% more likely to quit than those using placebos.
The effectiveness of these nicotine replacement tools are improved if done in combination with some kind of behavioral therapy. There are numerous behavioral approaches, often used together. Common ones include tapering or fading, scheduling or timing, motivational enhancements via rewards and punishments of different kinds, relapse prevention, cue exposure, aversion therapy, and others.
New medications to treat nicotine addiction are on the way, now that scientists realize that addictions stem from much more than “an addictive personality” or weak will. The remedies being tested actually target the cascade of neurochemical events at the root of addicts’ cravings.