Brandel France De Bravo, MPH, Sarah Miller, Jessica Becker, and Laura Gottschalk, PhD
Electronic cigarettes, or e-cigarettes, are being marketed as the “safe” new alternative to conventional cigarettes. But are e-cigarettes safe? What does the FDA think about them? Are e-cigarettes going to reverse the decline in smoking—giving new life to an old habit—or can they help people quit smoking? Here is what you need to know before picking up an e-cigarette.
WHAT ARE E-CIGARETTES?
E-cigarettes are battery-operated devices shaped like cigarettes that provide a way to get nicotine. Nicotine is an addictive drug (it stimulates and relaxes) that is naturally found in tobacco. The most popular way for people to take in nicotine is to inhale it by smoking cigarettes. E-cigarettes also allow nicotine to be inhaled, but they work by heating a liquid cartridge containing nicotine, flavors, and other chemicals into a vapor. Because e-cigarettes heat a liquid instead of tobacco, what is released is considered smokeless.1
ARE E-CIGARETTES SAFER THAN TRADITIONAL CIGARETTES?
The key difference between traditional cigarettes and e-cigarettes is that e-cigarettes don’t contain tobacco. But, it isn’t just the tobacco in cigarettes that causes cancer. Traditional cigarettes contain a laundry list of chemicals that are proven harmful, and e-cigarettes have some of these same chemicals.
Since 2009, FDA has pointed out that e-cigarettes contain “detectable levels of known carcinogens and toxic chemicals to which users could be exposed.”2 For example, in e-cigarette cartridges marketed as “tobacco-free,” the FDA detected a toxic compound found in antifreeze, tobacco-specific compounds that have been shown to cause cancer in humans, and other toxic tobacco-specific impurities.3 Another study looked at 42 of these liquid cartridges and determined that they contained formaldehyde, a chemical known to cause cancer in humans.4 Formaldehyde was found in several of the cartridges at levels much higher than the maximum EPA recommends for humans.
The body’s reaction to many of the chemicals in traditional cigarette smoke causes long-lasting inflammation, which in turn leads to chronic diseases like bronchitis, emphysema, and heart disease.5 Since e-cigarettes also contain many of the same toxic chemicals, there is no reason to believe that they will significantly reduce the risks for these diseases.
There are no long-term studies to back up claims that the vapor from e-cigarettes is less harmful than conventional smoke. Cancer takes years to develop, and e-cigarettes were only very recently introduced to the United States. It is almost impossible to determine if a product increases a person’s risk of cancer or not until the product has been around for at least 15-20 years. Despite positive reviews from e-cigarette users who enjoy being able to smoke them where regular cigarettes are prohibited, very little is known about their safety and long-term health effects.
CAN E-CIGARETTES BE USED TO CUT DOWN OR QUIT SMOKING REGULAR CIGARETTES?
If a company makes a claim that its product can be used to treat a disease or addiction, like nicotine addiction, it must provide studies to the FDA showing that its product is safe and effective for that use. On the basis of those studies, the FDA approves or doesn’t approve the product. So far, there are no large, high-quality studies looking at whether e-cigarettes can be used to cut down or quit smoking long-term. Most of the studies have been either very short term (6 months or less) or the participants were not randomly assigned to different methods to quit smoking, including e-cigarettes. Many of the studies are based on self-reported use of e-cigarettes. For example, a study done in four countries found that e-cigarette users were no more likely to quit than regular smokers even though 85% of them said they were using them to quit.6 Another year-long study, this one in the U.S., had similar findings.7 People may believe they are smoking e-cigarettes to help them quit, but 6-12 months after being first interviewed, nearly all of them are still smoking regular cigarettes.
Until there are results from well-conducted studies, the FDA has not approved e-cigarettes for use in quitting smoking.8
TEENAGERS, CHILDREN, AND E-CIGARETTES
The percentage of teenagers who have tried e-cigarettes has almost quadrupled in just four years, from 5% in 2011 to 19% in 2015. Three million U.S. students in middle school and high school tried e-cigarettes in 2015, according to the National Youth Tobacco Survey. And, 1 in 5 middle schoolers who said they had tried e-cigarettes also said they had never smoked conventional cigarettes.9
E-cigarette use by young people is worrisome for a number of reasons:
1) The younger people are when they begin smoking, the more likely it is they will develop the habit: nearly 9 out of 10 smokers started before they were 18.10
2) Nicotine and other chemicals found in e-cigarettes might harm brain development in younger people.11
3) E-cigarettes may introduce many more young people to smoking who might otherwise never have tried it, and once they are addicted to nicotine, some may decide to get their “fix” from regular cigarettes. Whether e-cigarettes end up being a “gateway” to regular cigarettes or not, young people who use them risk becoming addicted to nicotine and exposing their lungs to harmful chemicals.
The sharp rise in young e-cigarette users highlights the need to stop manufacturers from targeting teenagers with candy-like flavors and advertising campaigns.
Even children who are too young to smoke have been harmed by e-cigarettes. The liquid used in e-cigarettes is highly concentrated, so absorbing it through the skin or swallowing it is far more likely to require an emergency room visit than eating or swallowing regular cigarettes. In 2012, less than 50 kids under the age of six were reported to poison control hotlines per month because of e-cigarettes. In 2015, that number had skyrocketed to about 200 children a month, almost half of which were under the age of two!12
HOW ARE E-CIGARETTES REGULATED?
The FDA was given the power to regulate the manufacturing, labeling, distribution and marketing of all tobacco products in 2009 when President Obama signed into law the Family Smoking Prevention and Tobacco Control Act and in 2010 a court ruled that the FDA could regulate e-cigarettes as tobacco products.13
It wasn’t until 2016 that the FDA finally announced a rule to regulate e-cigarettes.14 Under the final rule, the FDA plans to ban the sale of e-cigarettes to anyone under the age of 18. The rule also requires all makers of e-cigarettes sold after February 15, 2007 to go through a “premarket review.” This is the process that the FDA uses to determine whether potentially risky products are safe. However, companies are allowed to have anywhere from 18 months to two years to prepare their applications. And it will take another year for the FDA to actually approve these applications. So don’t expect e-cigarettes currently on the market to be officially allowed to be sold by the FDA for another couple of years.
In the meantime, individual states have always had the power to pass laws restricting the sale and use of e-cigarettes. For example, in May 2013, the California state senate proposed a law making all e-cigarettes subject to the same regulations and restrictions as traditional cigarettes and tobacco products. However, that did not become law.
THE BOTTOM LINE
E-cigarettes have not been around long enough to determine if they are harmful to users in the long run. Unfortunately, many people, including teenagers, are under the impression that e-cigarettes are safe or that they are effective in helping people quit smoking regular cigarettes. Neither of these assumptions has yet been proven. Studies by the FDA show that e-cigarettes contain some of the same toxic chemicals as regular cigarettes, even though they don’t have tobacco. The big three tobacco companies—Lorillard, Reynolds American, and Altria Group—all have their own e-cigarette brands, so it’s not surprising that e-cigarettes are being marketed and advertised much the way regular cigarettes used to be. Here are the 7 Ways E-Cigarette Companies Are Copying Big Tobacco’s Playbook.
Unless you want to be a guinea pig, hold off on e-cigarettes until more safety information is available. And if you need help quitting or reducing the number of cigarettes you are smoking, check out the smokefree.gov website.
All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.
- Richard J. O’Connor font-style: inherit; font-weight: inherit; href=”http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716250/”>Non-cigarette tobacco products: What have we learned and where are we headed? Tob Control. Author manuscript; available in PMC 2013 July 19. Published in final edited form as: Tob Control. 2012 March; 21(2): 181–190. doi: 10.1136/tobaccocontrol-2011-050281. ▲
- Summary of Results: Laboratory Analysis of Electronic Cigarettes Conducted By FDA. style=”font-weight: inherit;”>FDA News & Events. FDA, 22 July 2009. <http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm173146.htm>. ▲
- Summary of Results: Laboratory Analysis of Electronic Cigarettes Conducted By FDA. style=”font-weight: inherit;”>FDA News & Events. FDA, 22 July 2009. Web. 09 Aug. 2013. <http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm173146.htm>. ▲
- Varlet et al. (2015) Toxicity of refill liquids for electronic cigarettes. style=”font-weight: inherit;”>International Journal for Environmental Research and Public Health. 12:4796-4815. ▲
- Stoller, JK & Juvelekian, G; Chronic Obstructive Pulmonary Disease; 2010 Cleveland Clinic Center for Continuing Education. clevelandclinic.meded.com/diseasemanagement/chronic-obstructive-pulmonary-disease ▲
- Adkison SE, O’Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med. 2013;44(3):207-215 ▲
- font-style: inherit; font-weight: inherit; href=”http://www.researchgate.net/researcher/2033394119_Rachel_A_Grana/”> Grana RA, href=”http://www.researchgate.net/researcher/2006915192_Lucy_Popova/”>Popova L, href=”http://www.researchgate.net/researcher/39480375_Pamela_M_Ling/”>Ling PM. A Longitudinal Analysis of Electronic Cigarette Use and Smoking Cessation. href=”http://www.researchgate.net/journal/2168-6114_JAMA_Internal_Medicine”>JAMA Internal Medicine, published online March 24, 2014 ▲
- Electronic Cigarettes style=”font-weight: inherit;”>FDA News & Events. FDA, 25 July 2013. font-style: inherit; font-weight: inherit; href=”http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm”>http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm>. ▲
- Singh T, Arrazola RA, Corey CG, et al. Tobacco Use Among Middle and High School Students – United States, 2011-2015. style=”font-weight: inherit;”>CDC Morbidity and Mortality Weekly Report. April 15, 2016. 65(14);361-367 ▲
- Centers for Disease Control and Prevention. Fact sheets: Youth and tobacco use. Available at: font-style: inherit; font-weight: inherit; href=”http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/”>http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/ ▲
- US Department of Health and Human Services. Preventing tobacco use among youth and young adults. Atlanta, GA: US Department of Health and Human Services, CDC; font-style: inherit; font-weight: inherit; href=”http://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm”>http://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm ▲
- Kamboj A, Spiller HA, Casavant MJ, et al. Pediatric Exposure to E-Cigarettes, Nicotine, and Tobacco Products in the United States. Pediatrics. May 2016. In Press. ▲
- “Regulation of E-Cigarettes and Other Tobacco Products.” FDA News & Events. FDA, April 25, 2011. font-style: inherit; font-weight: inherit; href=”http://www.fda.gov/newsevents/publichealthfocus/ucm252360.htm”>http://www.fda.gov/newsevents/publichealthfocus/ucm252360.htm>. ▲
- Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. 21 CFR Parts 1100, 1140, and 1143 (2016) ▲