Teens Take Up E-Cigs Instead of Smoking


Overall tobacco use among adolescents rose in 2014 over the previous year. Electronic cigarette use among U.S. middle and high school students tripled in 2014 while cigarette use fell to record lows, according to provocative new data that is likely to intensify debate over whether e-cigarettes are a boon or bane to public health.

Among high school students, e-cigarette use jumped to 13.4% in 2014 from 4.5% in 2013, according to the Centers for Disease Control and Prevention. Cigarette use over the same period fell to 9.2% from 12.7%, the largest year-over-year decline reported in more than a decade.

 Overall, tobacco use among high school students grew to 24.6% from 22.9%.

The data sparked alarm among tobacco control advocates who fear e-cigarettes will create a new generation of nicotine addicts who may eventually switch to conventional cigarettes.

“Nicotine exposure at a young age may cause lasting harm to brain development, promote addiction, and lead to sustained tobacco use,” Dr. Tom Frieden, director of the CDC, said in a statement.

Mitch Zeller, director of the Food and Drug Administration’s tobacco division, said the data “forces us to confront the reality that the progress we have made in reducing youth cigarette smoking rates is being threatened.”

But e-cigarette proponents argue that the CDC data could equally suggest that smoking rates fell because young people took up e-cigarettes instead of traditional cigarettes.

“There is no firm conclusion that one can draw from correlational data,” Jed Rose, director of the Center for Smoking Cessation at Duke University Medical Center, said in an interview.

“But it is equally amenable to the interpretation that e-cigarettes are diverting young people away from cigarettes.”

The data was drawn from the 2014 National Youth Tobacco Survey which showed current e-cigarette use, defined as use at least once in the past 30 days, surpassed current use of every other tobacco product for the first time.

It was not clear how many e-cigarette users were previously smokers and had switched. Altogether, 4.6 million middle and high school students were current users of any tobacco product. Of those, 2.2 million used at least two products.

The data showed hookah use nearly doubled to 9.4% from 5.2%, a disturbing trend since hookah smoking, in which smokers inhale burned tobacco through a water pipe, carries many of the same health risks as cigarette smoking.

An hour-long hookah smoking session involves 200 puffs, according to the CDC, while smoking an average cigarette involves 20 puffs. The amount of smoke inhaled during a typical hookah session is about 90,000 milliliters, compared with 500-600 milliliters inhaled from a cigarette.

“Hookah is very bad and is not a safer alternative to cigarette smoking because it has carbon monoxide and all sorts of cancer-causing agents,” Rose said. “It should not be confused with smokeless forms of nicotine use.”

The CDC said nearly half the students used more than one tobacco product. The most popular was e-cigarettes, followed by hookah. Cigarettes came in third place followed by cigars, smokeless tobacco and pipes.

Among middle school students, current e-cigarette use more than tripled to 3.9% in 2014 from 1.1% in 2013, while cigarette use remained unchanged, the CDC said.

Hookah use among middle school students jumped to 2.5% in 2014 from 1.1% in 2013. Overall tobacco use was 7.7% for middle school students in 2014.

The Food and Drug Administration regulates cigarettes, cigarette tobacco, roll-your-own tobacco and smokeless tobacco and expects to publish a rule extending its authority to e-cigarettes, hookah and other tobacco products in June.

“These staggering increases in such a short time underscore why FDA intends to regulate these additional products to protect public health,” Zeller said.

Electronic Cigarette Use and Exposure in the Pediatric Population


Electronic cigarette (e-cigarette) use has gained recent widespread popularity and acceptance in the general population. What effect e-cigarettes may have on pediatric health remains unknown. Although many jurisdictions have laws that prevent the sale of e-cigarettes to minors and the use of e-cigarettes in public places, infants, children, and adolescents are increasingly exposed to them. In this pediatric-focused review, we discuss the history of these devices, user demographics, known health effects, and current legislative efforts to protect minors from exposure.

Electronic Cigarette Is Also a Bluetooth Headset for Your Phone.


Who wants to be puffing on an electronic cigarette and holding a cell phone to their head at the same time? What are we? A bunch of savages?Bluetooth Cigarette
Supersmoker

Who wants to be puffing on an electronic cigarette and holding a cell phone to their head at the same time? What are we? A bunch of savages?

Thankfully, our long, international nightmare is over. For 80 Euro (roughly $110), you can get the Supersmoker Bluetooth, which is billed as an e-cigarette “that can be used to make calls and receive via Bluetooth and play music via the built-in microphone!”

If there’s a problem with this idea – and that’s a big if – it’s that you have to hold the cigarette against your head while you’re talking on it. That makes it hard-to-impossible to smoke it at the same time. Perhaps that’s nothing a short length of hose can’t fix, though.

Read more: FINALLY: Electronic Cigarette Is Also a Bluetooth Headset for Your Phone | TIME.com http://techland.time.com/2014/02/19/finally-electronic-cigarette-is-also-a-bluetooth-headset-for-your-phone/#ixzz2tsTjsOnU

Electronic Cigarettes Contain Higher Levels of Toxic Metal.


Electronic Cigarettes Found To Contain Dangerous Metal Nanopartices

A concerning new study found that the aerosol from electronic cigarettes contains higher levels of measurable nanoparticle heavy metals than conventional tobacco smoke.

A new study published in the journal PLoS One has uncovered a concerning fact about electronic cigarettes (EC): toxic metal and silicate particles including nanoparticles are present in both the cigarette fluid and aerosol.1

Researchers at the Department of Cell Biology and Neuroscience, University of California Riverside, tested the hypothesis that electronic cigarettes (EC) contain metals from various components in EC.  They employed a variety of testing methods to ascertain the level of contamination, including light and electron microscopy, cytotoxicity testing, and x-ray microanalysis. Their results were reported as follows:

The filament, a nickel-chromium wire, was coupled to a thicker copper wire coated with silver. The silver coating was sometimes missing. Four tin solder joints attached the wires to each other and coupled the copper/silver wire to the air tube and mouthpiece. All cartomizers had evidence of use before packaging (burn spots on the fibers and electrophoretic movement of fluid in the fibers). Fibers in two cartomizers had green deposits that contained copper. Centrifugation of the fibers produced large pellets containing tin. Tin particles and tin whiskers were identified in cartridge fluid and outer fibers. Cartomizer fluid with tin particles was cytotoxic in assays using human pulmonary fibroblasts. The aerosol contained particles >1 µm comprised of tin, silver, iron, nickel, aluminum, and silicate and nanoparticles (<100 nm) of tin, chromium and nickel. The concentrations of nine of eleven elements in EC aerosol were higher than or equal to the corresponding concentrations in conventional cigarette smoke. Many of the elements identified in EC aerosol are known to cause respiratory distress and disease.

The study authors concluded that “The presence of metal and silicate particles in cartomizer [atomizer/cartridge connecting to the battery] aerosol demonstrates the need for improved quality control in EC design and manufacture and studies on how EC aerosol impacts the health of users and bystanders.”

Cartomizer Anatomy

Discussion

While e-cigarettes are rightly marketed as safer than conventional tobacco cigarettes, which contain thousands of known toxic compounds including highly carcinogenic radioactive isotopes, they have not been without controversy.  In May 2009, the US Food and Drug Administration Division of Pharmaceutical Analysis found diethylene glycol, a poisonous liquid used in explosives and antifreeze, in one of the cartridges they sampled. They also discovered the cancer-causing agent, tobacco-specific nitrosamines, in a number of commonly used brands.2

The findings of this latest PLoS One study refutes proponents of e-cigarettes who claim that the health risks of smoking are eliminated with their use. Heavy metals like tin, aluminum, cadmium, lead and selenite are increasingly being recognized as carrying significant endocrine disrupting potential and belong to a class of metals known as ‘metalloestrogens.’

One of the unintended, adverse consequences of nanotechnology in general is that by making a substance substantially smaller in size than would occur naturally, or though pre-nanotech production processes, the substance may exhibit significantly higher toxicity when in nanoparticle form. Contrary to older toxicological risk models, less is more: by reducing a particle’s size the technology has now made that substance capable of evading the body’s natural defenses more easily, i.e. passing through pores in the skin or mucous membranes, evading immune and detoxification mechanisms that evolved millions of years before the nanotech era.

For example, when nickel particles are reduced in size to the nanometer range (one billionth of a meter wide) they may actually become more toxic to the endocrine system as now they are capable of direct molecular interaction with estrogen receptors in the body, disrupting their normal structure and function.3 4 5 Moreover, breathing these particles into the lungs, along with other metals, ethylene glycol and nicotine produces a chemical concoction exhibiting synergistic toxicity, i.e. the toxicity of the whole is higher than the sum of their parts. These sorts of “chemical soups” are exceedingly difficult to study, as they embody a complexity that analytical and theoretical models within toxicology are not equipped to readily handle. Nonetheless, it is likely that when taken together the harms done by e-cigarettes are significant, and will likely manifest only after chronic use when identifying ‘singular causes’ of disease is nearly impossible. Regulators will have a hard time, therefore, identifying a “smoking” gun even after a broad range of health issues do emerge in exposed populations.

Ultimately, finding a less harmful alternative to tobacco smoking is justified, but let buyer (and user) beware, the products are not without possible harm as some marketers falsely advertise.

 

E-cigarettes ‘could save millions’


Scientists say that if all smokers in the world switched from cigarettes to electronic cigarettes, it could save millions of lives.

Woman smoking an electronic cigarette

In the UK there are currently about 100,000 deaths per year attributable to smoking, worldwide it is estimated to be more than five million.

Now researchers are hopeful that an increasing use of e-cigarettes could prevent some of these deaths.

But some groups warn that e-cigarettes could normalise smoking.

An estimated 700,000 users smoke e-cigarettes in the UK, according to Action on Smoking and Health. Some users combine “vaping”, as it is often called, with traditional cigarettes while others substitute it for smoking completely.

E-cigarettes have also recently be found to be just as effective as nicotine patches in helping smokers quit.

Future hope

Rather than inhaling the toxic substances found in tobacco, e-cigarette users inhale vaporised liquid nicotine.

Robert West, professor of health psychology at University College London, told delegates at the 2013 E-Cigarette Summit at London’s Royal Society that “literally millions of lives” could be saved.

“Start Quote

Every adolescent tries something new, many try smoking. I would prefer they try e-cigarettes to regular cigarettes”

Dr Jacques Le Houezec Tobacco and nicotine researcher

“The big question, and why we’re here, is whether that goal can be realised and how best to do it… and what kind of cultural, regulatory environment can be put in place to make sure that’s achieved.

“I think it can be achieved but that’s a hope, a promise, not a reality,” he said.

A revolution

This view was echoed by Dr Jacques Le Houezec, a private consultant who has been researching the effects of nicotine and tobacco.

He said that because the harmful effects of its main comparator, tobacco, e-cigarette use should not be over-regulated.

“We’ve been in the field for very long, this for us is a revolution.

E-cigarettes
There is concern over the lack of regulation of e-cigarettes

“Every adolescent tries something new, many try smoking. I would prefer they try e-cigarettes to regular cigarettes.” Dr Le Houezec added.

Many are now calling for the industry to be regulated. An EU proposal to regulate e-cigarettes as a medicine was recently rejected, but in the UK e-cigarettes will be licensed as a medicine from 2016.

Konstantinos Farsalinos, from the University Hospital Gathuisberg, Belgium, said it was important for light regulation to be put in place “as soon as possible”.

“Companies are all hiding behind the lack of regulation and are not performing any tests on their products, this is a big problem.”

Prof Farsalinos studies the health impacts of e-cigarette vapour. Despite the lack of regulation, he remained positive about the health risks associated with inhaling it.

Healthy rats

E-cigarettes are still relatively new, so there is little in the way of long-term studies looking at their overall health impacts.

In order to have valid clinical data, a large group of e-cigarette users would need to be followed for many years.

Seeing as many users aim to stop smoking, following a large group of e-smokers for a long period could be difficult.

But in rats at least, a study showed that after they inhaled nicotine for two years, there were no harmful effects. This was found in a 1996 study before e-cigarettes were on the market, a study Dr Le Houezec said was reassuring.

Concern about the increase in e-cigarette use remains.

The World Health Organization advised that consumers should not use e-cigarettes until they are deemed safe. They said the potential risks “remain undetermined” and that the contents of the vapour emissions had not been thoroughly studied

Woman smoking electronic cigarette
E-cigarettes still divide opinion

The British Medical Association has called for a ban on public vaping in the same way that public smoking was banned.

They stated that a strong regulatory framework was needed to “restrict their marketing, sale and promotion so that it is only targeted at smokers as a way of cutting down and quitting, and does not appeal to non-smokers, in particular children and young people”.

Ram Moorthy, from the British Medical Association, said that their use normalises smoking behaviour.

“We don’t want that behaviour to be considered normal again and that e-cigarettes are used as an alternative for the areas that people cannot smoke,” he told BBC News.

But Lynne Dawkins, from the University of East London, said that while light-touch regulation was important, it must be treated with caution.

She said that e-cigarettes presented a “viable safer alternative” to offer to smokers.

“We don’t want to spoil this great opportunity we have for overseeing this unprecedented growth and evolving technology that has not been seen before, We have to be careful not to stump that.”

Hormone removes the pleasure of smoking.


The hormone GLP-1 is released when we eat and makes us feel full or sated toward the end of the meal.

 GLP-1 receptors are also activated in parts of the brain that are linked to satisfaction or a sense of reward. This indicates the hormone is directly involved in our experience of gratification.

Scientists reason that by blocking these receptors they can prevent smokers from feeling satisfied after a cigarette.

“Without this kind of reward, a smoker will not keep smoking. It can reduce addiction and the risk of a relapse,” says Elisabet Jerlhag, a researcher at the Sahlgrenska Academy of the University of Gothenburg.

Jerlhag and colleagues have investigated this new potential weapon in the battle against smoking.

Smokers require treatment

The ranks of daily, habitual smokers are on the decline but tobacco smoke remains a substantial public health challenge. One in four Norwegians smoke on occasion and the numbers of such “party smokers” are fairly stable.

Even those who are not heavy, daily smokers can find it hard to stub their cigs for good.

“Nicotine is remarkably habit-forming, and many people find it terribly hard to quit smoking. We need to start accepting dependency as a disorder that requires treatment,” says Jerlhag.

Tested on nicotine mice

To test whether GLP-1 regulates gratification, the researchers experimented with another chemical substance, Exendin-4 (Ex4), which imitates GLP-1’s effect on receptors. The substance was administered to a group of lab mice who had been given doses of nicotine.

The researchers then observed the mice’s movement patterns as well as the dopamine releases in their brains.

They found that nicotine made the mice more active, but the addition of Ex4 reduced that activity. However, mice that had not been given nicotine to start with did not experience the mitigating effect of Ex4. Nicotine increased the release of dopamine in their brains, but this was reduced when Ex4 had been given earlier.

The researchers concluded that GLP-1 receptors regulated the effect of nicotine on the reward functions in the brains of mice, and that Ex4 diminished the effect of nicotine.

Same effect on alcohol, amphetamines and cocaine

The researchers point out that other experiments have shown the same mitigating effect of Ex4 with other habit-forming substances such as alcohol, amphetamines and cocaine.

“Because Ex4 also reduced the motivation for consuming sucrose, this could indicate that GLP-1 receptors play a key role in the gratification created by addictive substances and the rewards of natural activities,” they add.

The researchers believe that substances that mimic the GLP-1 hormone should be considered for new prospective treatment regimens to help battle smoking and nicotine addiction.

Developing new medications

This method, which prevents smoking from soothing the nicotine cravings, is different from existing methods for treating habitual tobacco use, such as nicotine patches, or drugs such as bupropion or varenicline.

The hope is that the findings can lead to the development of new medications that mimic GLP-1. These kind of drugs have already been approved for diabetes, so that it should be relatively easy to get the green light to use them to help smokers kick their habit.

“Rewards are a prime reason why we become addicts. So we think medications that work in the same way as GLP-1 can have a positive impact on nicotine dependency. This is a whole new approach,”  Jerlhag says.

If you think the timing is wrong for quitting cigarettes, you are wrong – Now is the time.


I bet you didn’t know that nicotine in commercial cigarettes is up to 35 times stronger than it was in the 1950’s and early 1960’s, before Big Tobacco (Marlboro and Kool) started using ammonia to free-base it. That is the number one reason why 95% of smokers who try to quit without help will return to smoking within 6 months. Nicotine is artificial chemical control of your emotions. Some people are switching to e-cigs (electronic cigarettes), so they can keep their nicotine addiction going strong while eliminating “some” of the chemicals found in the commercial cancer sticks. Other people quit cold turkey, usually after finding out they have cancer, or after a close friend or relative winds up six feet under from the nicotine nightmare. Talk about bad timing.

Old-Cigarettes-Trash-Ashtray

Quitting “cold turkey” is very difficult. Most people who quit smoking “cave in” and start back up again within half a year, but why? That’s because most programs give little to zero advice about nutrition and building back up the nutrients and the gut “flora” (good bacteria), which is destroyed by the 4,000 chemicals in every cigarette. Also, behavior rituals like breathing patterns and hand to mouth habits must be replaced with positive ones, or they will be missed and might cause a relapse. (http://www.naturalnews.com)

Plus, on top of everything else that sends smokers back to the well, toxic food and high blood acidity can cause nicotine withdrawal symptoms to flare up and the “urge to smoke” seem more “necessary,” leading to temporary relief from cravings and stressful moments, only to drag the person back into the undertow of chemical addiction and artificial emotion control. (http://www.naturalnews.com)

On top of the big “hooks” that keep smokers addicted, the cigarette industry spends about $23,000,000 a day on advertising and promotions. The statistics are all consuming, and cigarettes cause about 5 million deaths annually worldwide. Still, people smoke and wonder why they don’t quit. Want to know why? They can’t quit because they don’t know how. Even though “Big Tobacco” got busted for fraud and settled in the billions, they’re still up to no good, free-basing nicotine and brainwashing people into the habit from which they just can’t seem to “escape.”
(http://www.cdc.gov)

23 million smokers in U.S. wish they could QUIT today

There are 46,000,000 smokers in the U.S. alone and half want to quit, but only 5% will succeed. Scary ads don’t work, and commercial cigarettes are STILL JUICED UP WITH AMMONIA, despite settling with Blue Cross Blue Shield to the tune of $6.5 billion in the 1990’s for doing just that and also marketing to children and teens. “More than 15 years has passed since the conclusion of the Minnesota tobacco trial and the signing of the Master Settlement Agreement (MSA) by 46 U.S. State Attorney Generals and the US tobacco industry. The Minnesota settlement exposed the tobacco industry’s long history of deceptive marketing, advertising, and research and ultimately forced the industry to change its business practices. It has also been more than 15 years since the tobacco industry’s individual settlements with the states of Mississippi (1997), Florida (1997), and Texas (1998) … These agreements are the 5 largest settlements in the history of litigation.” (http://www.ncbi.nlm.nih.gov)

The CDC scary advertising campaign is also a dismal failure, only helping about 4% of the people who see it quit smoking, half of whom go back to smoking within 6 months, so what’s the use? Although the CDC brags that 1.6 million people TRIED to quit thanks to their scary ad campaign, how many really did quit? You can’t just scare people out of the third strongest addictive drug on the planet (nicotine); people need guidance and nutritional help.
(http://www.examiner.com)

The Number One Excuse is “Bad Timing”

The single most popular excuse that people use for not quitting is that the timing is wrong. They will say that times are TOO stressful, so they’ll have to wait, but the last thing the body needs while it’s under stress is ammonia, bleach, pesticide and plastic fumes entering the lungs, attached to chemical tar and glass fibers that cut the epithelial tissue. This breaks down the person’s immunity and makes them more susceptible to common colds, flu, viruses, bacterial infections, nasal congestion, allergies, sinus infections, bronchial infections, bladder infections, depression, sleep disorders and more. So go figure. Who needs all of that when times are stressful? Some people turn to electronic cigarettes to filter out some of the chemicals contained in commercial cigarettes (except for diethylene glycol – antifreeze – which causes leukemia!), but many of those people learn a hard lesson: nicotine damages the central cleansing organs and causes a host of its own problems, short term and long term, so bragging rights there are few and far between. (http://www.naturalnews.com)

One way out of the nicotine “prison” is to combine chemical knowledge with behavior modification and nutritional guidance. These three factors and skill bases, when taught and used correctly, have the highest success rate for helping smokers quit and stay smoke-free for life. There is a natural method that incorporates all three of these phases and is receiving excellent reviews. Studies show that smokers who seek help and follow the “yellow brick road” to a smoke-free life have an easier time “sticking to their guns.” The 14AndOut one hour program (video of the class) teaches smokers how to wean themselves off commercial cigarettes in 14 days or less and is recommended by Mike Adams, the Health Ranger and Editor of Natural News. The program has been a sensation for the past two years and there is nothing else like it on the market right now. Give 14AndOut a try and share the natural method with your friends, co-workers, relatives and/or neighbors who smoke cigarettes and speak of quitting. Stop smoking before 2014 and bring in the New Year with style and good health. Where there is a will, there is a way!

The Regulatory Challenge of Electronic Cigarettes.


Electronic cigarettes (e-cigarettes or electronic nicotine delivery systems) heat a nicotine solution to generate vapor that is inhaled, without the combustion of tobacco and its toxic constituents. Use of e-cigarettes is increasing in the United States and around the world. Current smokers in the United States report an 11.4% prevalence of ever use of e-cigarettes and 4.1% use in past 30 days.1 They likely pose less direct hazard to the individual smoker than tobacco cigarettes and might help smokers quit smoking or reduce harm by smoking fewer tobacco cigarettes. On the other hand, there are potential harms, including promoting continued smoking of cigarettes and renormalizing cigarette smoking behaviors. The Food and Drug Administration (FDA) is authorized to regulate tobacco products, and in 2011 the agency announced plans to regulate e-cigarettes as tobacco products.2 The FDA will need to make a number of regulatory decisions about product safety that could have major effects on public health and will face many challenges.

THE E-CIGARETTE AS A NICOTINE DELIVERY SYSTEM

The delivery of nicotine to the lungs via inhalation, with rapid absorption into the circulation, is critical to the addictiveness of cigarette smoking.3 The adverse health consequences of cigarette smoking are caused primarily by inhalation of toxic tobacco constituents and organic combustion products. Nicotine per se contributes to some smoking-related diseases, but its contribution is considered to be much smaller than that of combustion products.3 The provision of clean nicotine (without combustion products or other tobacco plant toxins) in the form of nicotine replacement therapies (NRTs) has been in use for nearly 30 years and has proven to be a safe way to facilitate smoking cessation. Currently available NRT products are not as satisfying and are less acceptable to smokers compared with inhaling and absorbing nicotine from cigarette smoke. The possibility of an inhaled clean nicotine device has been discussed by health researchers for many years as a potentially more effective way to promote smoking cessation. Although not yet proven safe or effective for smoking cessation, the e-cigarette has been positioned as such an inhaled nicotine delivery device and has gained popularity through this perception.4

PRODUCT EVOLUTION

More than 250 e-cigarette brands are on the market currently, and products have evolved rapidly in recent years. Different e-cigarette brands are engineered differently, affecting the character and potential toxicity of the vapor. Thus, it is difficult to generalize about e-cigarettes as a single device. The FDA will need to consider the engineering of e-cigarettes with respect to different types of nicotine solutions, the capacity of the cartridges containing the solution, the nature of the heating element and battery, the types of additives and flavorings, and the potential toxicants released in the vapor.

ASSESSING POTENTIAL TOXICITY AND HEALTH EFFECTS

Liquids used in e-cigarettes vary with respect to concentrations of toxicants, and the quality control in e-cigarette manufacturing is questionable.5 Although a number of toxicants have been identified in e-cigarette vapors, the levels of these toxicants are orders of magnitude lower than those found in cigarette smoke, although higher than those found in NRT.6 Although it cannot be said that currently marketed e-cigarettes are safe, e-cigarette vapor is likely to be much less toxic than cigarette smoke. Among the questions that should be considered by the FDA are (1) Do low levels of contaminants in e-cigarette vapor pose a health risk? (2) What are the thresholds for toxicity of contaminants in vapor? (3) What should be the basis for product standards for e-cigarettes? (4) Could the risks be ameliorated by changes in engineering?

POTENTIAL HEALTH BENEFITS FOR INDIVIDUAL SMOKERS

Testimonials, surveys, and one uncontrolled clinical trial report that e-cigarettes facilitate the quitting of cigarette smoking and allow smokers to smoke fewer cigarettes per day if they continue to smoke.7– 8However, longitudinal analysis using population-level data found no difference in quit rates between e-cigarette users and nonusers.9 Controlled clinical trials and population-level observational cohort studies are needed to establish the utility of these cigarettes to facilitate smoking cessation. Research is also needed regarding the role of e-cigarettes in harm reduction, including reduced cigarette smoking and associated reduction of tobacco toxicant exposure. The FDA will need to determine the magnitude of potential health benefits from e-cigarettes for individual smokers.

POTENTIAL POPULATION HARM

Several potential sources of population harm require research and subsequent weighing of individual benefit vs population risk. These include uptake of e-cigarette use by nonsmokers, who may later become cigarette smokers or long-term nicotine addicts; promotion of dual use of e-cigarettes and regular cigarettes, such that use of e-cigarettes undermines quitting cigarette smoking; undermining the denormalization of cigarette smoking, because e-cigarettes look like regular cigarettes and their use in public would give the appearance that cigarette smoking behavior is more acceptable; and exposure to a new source of air pollution in places covered by smoke-free policies.

ADVERTISING AND MARKETING

Advertising and marketing can be considered in the context of both manufacturer and consumer. Industry has been aggressively marketing e-cigarettes with claims of health benefit compared with smoking tobacco cigarettes, for reducing and quitting smoking, for smoking without generating irritating and harmful secondhand smoke, and for using when a person cannot smoke cigarettes.10 Marketing also uses young models and celebrities to convey images of the product as glamorous and modern. The net result of industry marketing and consumer advocacy has been a substantial increase in the use of the product. Effective promotion of e-cigarettes could be advantageous if it was determined there was individual health benefit and a low level of total population harm—for example, if e-cigarette use was found to facilitate smoking cessation and not encourage dual use or appeal to youth as a novel nicotine product.

The FDA needs to decide how marketing should be regulated in the context of potential benefits and population risks. This includes deciding the legal age at which minors can purchase the products and other possible access restrictions, as well as evaluating the appeal of the marketing to youth. Determining the effect of e-cigarettes on the entire population will be challenging.

BROADER REGULATORY ISSUES

Assuming that e-cigarettes of high quality could be safe and could offer net public health benefit (including high consumer acceptability, more effective nicotine delivery, low levels of contaminants, not undermining existing tobacco control efforts), and that product improvement is occurring in an environment of marketplace competition, a critical question is when the FDA should begin to require product licensing. A disadvantage of requiring licensing is that regulatory requirements are likely to slow product innovation. The advantage of licensing would be to ensure the quality and consistency of products.

Medications to promote smoking cessation are regulated by the FDA Center for Drug Evaluation and Research (CDER). Tobacco products are regulated by the FDA Center for Tobacco Products (CTP). According to current FDA regulations, in the event that e-cigarettes are found to be helpful in facilitating smoking cessation, the same product could be regulated simultaneously, both by CDER as a medication and by CTP as a tobacco product. This makes little practical sense. A comprehensive regulatory approach to nicotine-containing products is needed. Regulation needs to include the full spectrum of products, from the most hazardous to the least hazardous, with consideration of the potential of less harmful products to reduce exposure to the most harmful combustion products from smoked tobacco, while simultaneously evaluating the total public health effects of the policies.

Source: JAMA

Should electronic cigarettes be as freely available as tobacco cigarettes? No.


The Medicines and Healthcare Products Regulatory Agency has decided to license electronic cigarettes as medicines from 2016. Simon Chapman agrees with regulation, seeing e-cigarettes as another way for big tobacco to try to make nicotine addiction socially acceptable again, but Jean-François Etter (doi:10.1136/bmj.f3845) says restrictions will result in more harm to smokers

Amid the feverish embrace of electronic cigarettes, come several statements by the tobacco industry that should cause public health proponents of such products to get a grip. For example, the chief executive of Reynolds America told shareholders in November 2012, just six months before entering the e-cigarette market, “We have a little mantra inside of the company . . . which we call the 80-90-90 . . . We spend about 80% of our resources in the combustible space. The combustible space is still 80%, 80+% of our operating income . . . [and] 90% of the organizational focus . . . And despite a lot of these new innovations that you see coming out, 90% of our R&D [research and development] budgets are actually directed at the combustible category . . . That is the category that’s still going to deliver a lot of growth into the future.”1

Misconceptions

Big tobacco is not investing in e-cigarettes to wean itself off cigarette sales. Its recent

oleaginous rhetoric about them saving lives is utter duplicity. None of the big companies now in the e-cigarettes market have desisted from virulent opposition to policies that are known to reduce smoking. None has declared accelerated targets for reducing cigarette sales. As with other forms of smokeless tobacco, big tobacco wants smokers to use e-cigarettes as well as cigarettes, not instead of them. Its five goals are widespread dual use; retarding smoking cessation; resocialising public smoking back into fashion from its forlorn exile outside buildings; conveying to young, apprehensive would-be smokers that nicotine is a benign drug; and welcoming back lapsed smokers.

If big tobacco succeeds with any of these ambitions, e-cigarettes may cause a net increase in population harm. Urged on by myopic health professionals who seem to have lost any population health focus they might have had, this may become one of the biggest blunders of modern public health.

Public health enthusiasts for e-cigarettes see their promise as a way to get smokers to quit or reduce toxic exposure, but they seem blasé about the other possible effects described above. There are many impassioned, vocal testimonies that e-cigarettes have helped many thousands to quit or cut down smoking. But the first prospective study found that although smoking cessation and harm reduction motivated many e-cigarette users, there were no differences in smoking quit rates between e-cigarette users and non-users.2 And importantly, cutting down cigarettes rather than quitting confers little if any health benefit,3 so dual use may be as bad as continued smoking in terms of health outcomes.

Regulation is required

So how should we respond to e-cigarettes? The first step must be to move beyond anecdotal testimony and naive optimism and study large populations to build the evidence about whether e-cigarettes do accelerate quitting and to quantify behaviours indicative of the important industry goals above.

Tobacco use may kill a billion people this century,4 largely because of tobacco’s historic treatment as an unexceptional item of commerce and, later, decades of glacial action by governments failing to regulate this dangerous consumer product. But in the past 50 years, we have learnt much about how to reduce tobacco use—for example, only 15.7% of Australians aged 15 or over now smoke daily,5 and youth smoking has never been lower.6 We are finally pulling access to tobacco products back to where it should have started: expensive, highly regulated, non-advertised, plain packaged, and out of retail sight.

We should make none of the many disastrous mistakes made with cigarettes in the name of allowing e-cigarettes to compete better with cigarettes. We should start by not assuming they are benign items of commerce. Drug companies have long been able to sell nicotine in small doses as a quitting aid but have never tried to register high dose products. Their awareness of the role of nicotine in apoptosis, angiogenesis, inflammation, and cell proliferation7 8 9 has always put the brakes on any temptation to have regulatory agencies allow them to sell products with doses that genuinely compete with cigarettes. So why should e-cigarettes, for which users can create their own e-juice, escape such regulation?

Many smokers want to access e-cigarettes to quit or reduce risk, and they should not be denied this opportunity. But the needs of often desperate smokers must not become the tail that wags the dog of tobacco control policy, putting at risk the massive gains we have achieved. The advent of e-cigarettes provides a perfect pretext to introduce a form of user licence for nicotine products in the same way that access to potent drugs has long required a temporary licence (a prescription) for those who need them.10 This would balance the right to use e-cigarettes with all the constraints and disincentives that are now, and should be further, applied to cigarettes. For countries where e-cigarettes are virtually “off the leash” this will probably be impossible. But for most nations that have acted cautiously, e-cigarettes may in fact turn out to be a Trojan horse, stimulating regulators to take more seriously the regulation of all tobacco and nicotine products—not just pharmaceutical nicotine—regardless of the motive of the individual user or the stated and unstated motives of the manufacturer.

Notes

Cite this as: BMJ 2013;346:f3840

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
  • Read Jean-François Etter’s side of the debate at doi:10.1136/bmj.f3845.
  • Provenance and peer review: Commissioned; not externally peer reviewed.

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Adkison SE, O’Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong H-H, et al. Electronic nicotine delivery systems. International tobacco control four-country survey. Am J Prev Med2013;44:207–15.

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Australian Bureau of Statistics. Australian health survey: first results, 2011-12.www.abs.gov.au/ausstats/abs@.nsf/Lookup/73963BA1EA6D6221CA257AA30014BE3E?opendocument.

Tobacco in Australia. Facts and issues. www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-6-prevalence-of-smoking-secondary-students.

Zeidler R, Albermann K, Lang S. Nicotine and apoptosis. Apoptosis2007;12:1927-43.

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Chen RJ, Ho YS, Guo HR, Wang YJ. Rapid activation of Stat3 and ERK1/2 by nicotine modulates cell proliferation in human bladder cancer cells. Toxicol Sci2008;104:283-93.

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Vassallo R, Kroening PR, Parambil J, Kita H. Nicotine and oxidative cigarette smoke constituents induce immune-modulatory and pro-inflammatory dendritic cell responses. Mol Immunol2008;45:3321-9.

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Chapman S. The case for a smoker’s license. PLoS Med2012;9:e1001342.

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Source: BMJ

 

 

E-cigarettes face new restrictions.


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Electronic cigarettes will be licensed as a medicine in the UK from 2016, under new regulations.

The UK currently has few restrictions on the use of e-cigarettes, despite moves in some countries to ban them.

The Medicines and Healthcare Products Regulatory Agency says it will regulate e-cigarettes as medicines when new European tobacco laws come into force.

Sales of tobacco-free cigarettes have boomed worldwide since bans on smoking in public places were introduced.

Campaigners say the growing popularity of e-cigarettes could undermine years of anti-smoking efforts, with particular concerns about promotion to children and non-smokers.

Research suggests around 1.3m smokers and ex-smokers in the UK use the products, which are designed to replicate smoking behaviour without the use of tobacco.

They turn nicotine and other chemicals into a vapour that is inhaled.

 “Start Quote

Regulation can ensure that adult smokers can continue to be able to buy e-cigarettes as easily as tobacco, but promotion to children or non-smokers will be prohibited”

Deborah ArnottASH

Jeremy Mean of The Medicines and Healthcare Products Regulatory Agency (MHRA) said the government had concluded that e-cigarettes currently on the market do not meet appropriate standards of safety, quality and efficacy.

He said “levels of contamination” had been found in the products and some were poorly manufactured.

Not recommended

There will be no compulsory licensing of the products until 2016 but until then they are not recommended for use, he said.

“We can’t recommend these products because their safety and quality is not assured, and so we will recommend that people don’t use them,” he told a news conference.

The MHRA had decided not to ban the products entirely but to work towards a position where they are licensed, he added.

“Smoking is the riskiest thing you can do – we want to enable people to cut down and quit – we don’t think a ban is a proportionate action.”

The health campaign body, Action on Smoking and Health (ASH), said the action will ensure promotion to children or non-smokers is prohibited.

E-cigarettes: pros and cons

  • The British Medical Association says health professionals should encourage their patients to use a regulated and licensed nicotine replacement therapy (such as patches or gum) to help quit smoking
  • It says health professional may advise patients that while e-cigarettes are unregulated and their safety cannot be assured, they are likely to be a lower risk option than continuing to smoke

Deborah Arnott, chief executive of ASH, said: “MHRA regulation can ensure that adult smokers can continue to be able to buy e-cigarettes as easily as tobacco, but promotion to children or non-smokers will be prohibited.”

Chief Medical Officer Professor Dame Sally Davies said with more people using e-cigarettes it was only right that the products were properly regulated to be safe and work effectively.

“Smokers are harmed by the deadly tar and toxins in tobacco smoke, not the nicotine,” she said.

“While it’s best to quit completely, I realise that not every smoker can and it is much better to get nicotine from safer sources such as nicotine replacement therapy.”

Manufacturers of e-cigarettes say the products have the potential to save lives and should not be restricted.

Adrian Everrett, chief executive officer of E-Lites, told the BBC: “So far not one person globally has been killed by an electronic cigarette and yet every 5 minutes in this country alone someone dies from tobacco use.

“To remove or restrict the use or availability of the electronic cigarette from this market would be a significant health loss.”

Once licensed, e-cigarettes are expected to remain on sale over-the-counter in the UK.

In some countries, such as New Zealand, e-cigarettes are regulated as medicines and can be purchased only in pharmacies.

In other countries, including Denmark, Canada and Australia, they are subject to restrictions on sale, import and marketing. Complete bans are in place in Brazil, Norway and Singapore.

Dr Mike Knapton, Associate Medical Director at the British Heart Foundation, said more research was needed into the potential health implications of long-term nicotine use.

“The MHRA has rightly addressed the worrying dearth of regulation around nicotine-containing products and electronic cigarettes – an important step to ensuring their safety,” he said.

“Marketing of these products must now be closely monitored to ensure non-smokers and children don’t end up using them.”

Source: BBC