E-Cigarette Smoking Could be Banned at L.A. Restaurants, Beaches


Thumbnail image for e_cigarette_Michael_Dorausch_Flickr_ok.JPG
Michael Dorausch/Flickr

Hold onto to your e-cigarettes while you can, people, because using them might soon be banned in the same places that prohibit lighting up regular smokes.

The L.A. City Council today will consider a new motion to be introduced by Councilman Mitch O’Farrell that would treat electronic devices the same way that cigarette smoking is regulated in town.

And means no puffing, electronic or otherwise, in or on:

-elevators
-supermarkets
offices
-restaurants
-city beaches, or
-within 25 feet of playground equipment, bleachers, backstops, sports courts and fields, and picnic areas.

Yep. O’Farrell’s spokesman, Tony Arranaga, confirmed to the Weekly the gist of today’s proposal.

According to a statement put out by the offices of O’Farrell and the City Attorney:

The motion directs the City Attorney’s office to draft an ordinance to regulate the usage of electronic smoking devices where smoking is prohibited by law.

But wait, there’s more:

The council today will also weigh Councilman Paul Koretz‘s motion to raise the age limit on e-cigarette purchases to those 18 or older. As it stands, electronic tobacco retailing has no age limit for customers.

There have also been efforts on the state level to treat the battery-operated “vapes” (for nicotine vaporizers or atomizers) the same as regular cigs.

Proponents of e-cigarettes have been enjoying loopholes in the law, often smoking at bars and restaurants without reprisal. They argue that the water vapor emitted by the devices is not smoke and that it is not harmful.

However, some critics say that scientific testing has yet to catch up with the devices. The jury is still out about whether they are the source of second-hand smoke danger.

Heavy smokers cut down or quit after magnetic brain stimulation, study finds.


Heavy smokers who regularly puffed more than a packet of cigarettes a day cut down or quit for six months after their brains were stimulated with magnets, researchers say.

The apparent success of the simple procedure has led the scientists to organise a large-scale trial which will launch early next year at 15 medical centres worldwide.

Smokers in the pilot study had already tried anti-smoking drugs, nicotine gum and patches or psychotherapy to no avail, raising hopes that magnetic stimulation might offer an effective alternative for those who want to give up but have so far failed.

Nearly half of the smokers in one group, who received high-frequency magnetic pulses, quit after a three-week course of stimulation, with more than a third still abstaining six months on.

“This is a new approach to the problem,” said neuroscientist Abraham Zangen of Ben-Gurion University in Israel. “These are heavy smokers who could not stop smoking before.”

More trials will be needed to prove the value of the procedure, which scientists say should only be offered within a psychotherapy-based programme designed specifically for smokers.

For the pilot study, Zangen recruited 115 people aged 21-70 who smoked at least 20 a day. Only those who had tried to give up before using at least two methods were allowed to take part in the programme.

The smokers were divided into three groups. The first had 15 minutes of high-frequency magnetic stimulation every weekday for two weeks, followed by three sessions in the third week.

The second group had the same number of sessions of low-frequency magnetic stimulation. The third group thought they were having their brains stimulated, but the device was actually turned off to provide a control group.

Before each session, one of Zangen’s PhD students lit a cigarette and took a puff in front of half of the smokers in each group. This was designed to awaken their cravings for a smoke, and hopefully make them more susceptible to the treatment.

Zangen targeted brain regions called the prefrontal cortex and insula with a technique called deep repeated transcranial magnetic stimulation, or rTMS. Throughout the study, he asked the smokers to record how much they smoked up until six months later.

The results showed a placebo effect, or an improvement without any proper intervention, in the control group, and also in the smokers who received low frequency stimulation. In both of these groups, the smokers cut down on average from 26 to 20 cigarettes a day.

But the results were more impressive in the smokers who had high-frequency brain stimulation after witnessing one of the scientists have a drag on a cigarette: 44% quit after the three-week course and six months later, 36% said they were still not smoking.

To check that the smokers were telling the truth, Zangen tested their urine for a breakdown product of nicotine called cotinine. The results were in line with the smokers’ claims.

Though the findings are promising, the study was too small to be convincing. Zangen said a much larger trial, involving medical centres in several countries, was due to start in the next few months to test the stimulation on far more smokers.

More than a third of those treated with high frequency magnetic pulses stopped smoking for at least six months, researchers say.

If the procedure turns out to be effective, smokers might not need to have their brains stimulated regularly to avoid relapsing, he said.

“It’s quite easy to quit for a few days, or even for a few weeks, but if we can help people quit for more than three months, then they are actually quite unlikely to relapse later on,” he said.

A man smoking a cigarette

Peter Eichhammer, who has studied brain stimulation at the University of Regensburg, said that while the procedure might be effective, it was important for smokers to receive treatment in a dedicated psychotherapy-based programme.

“rTMS may help people to reduce smoking, most likely by mimicking nicotine’s actions on the brain reward system,” he said. “But it does not substitute a special psychological therapy. In general, I would be very cautious to promote rTMS as a sole biologically-driven therapeutical strategy.

“rTMS may be helpful but should be embedded in a psychological therapeutical program. Moreover, we need replication from a variety of clinical studies which really treat people with this addiction,” he said.

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.”

Menthol cigarettes: Stub out these seductive smokes.


Menthol cigarettes make it easier to start smoking and harder to quit. It’s time to stub them out for good

SMOKING may be under siege, but it is still the world’s second biggest cause of preventable death. Tobacco kills nearly 6 million people every year, approximately 10 per cent of all deaths. Smoking also results in hundreds of billions of dollars in economic costs from increased healthcare expenditure and lost productivity.

<i>(Image: Andrzej Krauze)</i>

In the West, anti-smoking campaigns seem to have stalled. Around 1 in 5 US adults smokes, about the same as 10 years ago. Now those who seek to further reduce the harm from smoking have proposed a new measure: a ban on menthol in cigarettes.

Last week, after months of intense debate, the European Parliament voted for a ban on menthol cigarettes, which will come into force in 2022. Similar moves are afoot in the US, again surrounded by intense debate.

Menthol cigarettes were invented in the 1920s by Lloyd “Spud” Hughes of Mingo Junction, Ohio, who reportedly stored his cigarettes in a tin with menthol crystals that he used to treat a persistent cold. The tobacco absorbed the mint flavour and made the cigarettes easier to smoke. Hughes began selling mentholated cigarettes, and by 1932 his Spud brand was the fifth bestselling cigarette in the country.

Today, about a quarter of cigarettes sold in the US are menthol; 30 per cent of adult smokers and more than 40 per cent of youth smokers report smoking them.

In 2009, the US passed a law that for the first time gave the Food and Drug Administration (FDA) the authority to regulate tobacco products. Among other things, the agency now has the power to regulate the levels of “harmful components” they contain.

The FDA quickly acted to ban flavourings such as chocolate and vanilla, which are thought to be particularly attractive to children and teenagers. But it stopped short of banning menthol – the most popular additive – pending further studies.

Menthol is not simply a flavour additive: it can also have drug-like effects. In addition to its fresh taste and aroma, it can produce cooling, soothing sensations, which is why it is an ingredient in a number of medicinal products, such as throat lozenges. Menthol produces these effects by binding to receptors on sensory neurons which mediate signals related to pain, temperature and irritation. Low doses of menthol in cigarette smoke can therefore reduce the painful and irritating effects on the lining of the nose, mouth and airways, thereby allowing smokers to inhale more easily.

An analysis of internal tobacco industry documents from 1965 to 2000 identifies two types of menthol smoker. The first are people for whom menthol primarily serves to reduce the harsh effects of smoke. These people tend to be occasional smokers or young smokers. The second are people for whom it provides a stronger flavour and physical sensation. In the US, they tend to be African American men.

Data from numerous surveys and research projects confirm these findings. Adolescents aged between 12 and 17, for example, smoke menthol cigarettes at a higher rate than older age groups. The same is true for young adults aged 18 to 24.

The fact that menthol cigarettes are favoured by adolescents and young smokers leads to the suspicion that their availability encourages people to smoke, and this, too, is supported by research. In 2011, a report from the FDA’s Tobacco Products Scientific Advisory Committee concluded that “there is strong evidence indicating that adolescent menthol cigarette smokers are more dependent on nicotine than adolescent non-menthol cigarette smokers”.

The increased use of menthol cigarettes among African Americans, meanwhile, suggests that their availability results in disproportionate harm to that section of society.

In July the FDA said it was “likely” that menthol cigarettes posed a greater health risk than normal cigarettes, because they encourage young people to take up smoking, make it more difficult to quit and increase addiction. The agency opened a public consultation period, due to end on 22 November, with a view to an eventual ban.

The primary counterargument put forward by the tobacco industry is that a ban would create a black market for menthol cigarettes. However, the evidence for this is weak. One study directly asked smokers of menthol cigarettes how they would respond if the product was no longer sold. Thirty nine per cent said they would quit and 36 per cent said they would switch to non-menthol cigarettes.

In another study that included the response “seek out illicit products”, only 25 per cent indicated that they might consider purchasing black market products. These findings do not suggest that there would be an explosion of illicit activity if menthol cigarettes were banned.

In light of the tremendous threat that tobacco use poses to health and the minimal risk that would be expected from banning menthol cigarettes, the risk/benefit calculation appears to favour a ban. This opinion is shared by several leading health organisations, including the American Cancer Society, American Heart Association, American Lung Association, American Academy of Pediatrics, African American Tobacco Control Leadership Council and American Public Health Association. These organisations recently submitted a petition to the commissioner of the FDA to request the prohibition of the use of menthol.

We will only know how a ban on menthol cigarettes will pan out when we actually test it outside the laboratory. There is a growing consensus that the science is telling us it is time to conduct the experiment.

This article appeared in print under the headline “Not smooth, not cool”

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.

Growing Evidence Of Marijuana Smoke’s Potential Dangers.


In a finding that challenges the increasingly popular belief that smoking marijuana is less harmful to health than smoking tobacco, researchers in Canada are reporting that smoking marijuana, like smoking tobacco, has toxic effects on cells.

Rebecca Maertens and colleagues note that people often view marijuana as a “natural” product and less harmful than tobacco. As public attitudes toward marijuana change and legal restrictions ease in some countries, use of marijuana is increasing.

Scientists know that marijuana smoke has adverse effects on the lungs. However, there is little knowledge about marijuana’s potential to cause lung cancer due to the difficulty in identifying and studying people who have smoked only marijuana.

The new study begins to address that question by comparing marijuana smoke vs. tobacco smoke in terms of toxicity to cells and to DNA. Scientists exposed cultured animal cells and bacteria to condensed smoke samples from both marijuana and tobacco. There were distinct differences in the degree and type of toxicity elicited by marijuana and cigarette smoke.

Marijuana smoke caused significantly more damage to cells and DNA than tobacco smoke, the researchers note. However, tobacco smoke caused chromosome damage while marijuana did not.

Source: : http://www.sciencedaily.com

Doctors Asked to Counsel Teens About the Dangers of Smoking.


Doctors already have a hefty checklist of topics to go over with their patients. Will they be able to squeeze in discussions about the health hazards of tobacco during office visits?

The recommendation, published in the Annals of Internal Medicine and Pediatrics, that primary-care physicians start counseling younger patients about tobacco updates the U.S. Preventive Services Task Force (USPSTF) advice from 2003. At that time, the task force of experts could not find enough evidence to ask physicians to intervene with talks about tobacco during checkups with teens and adolescents. Since then, however, the panel says more studies have shown that conversations with physicians can have an impact in reducing smoking and other tobacco use among teens.

smoking_1117

The members analyzed trials that were designed to either prevent smoking among adolescents or to encourage them to quit. Youngsters who were told about antitobacco programs by their primary-care physicians were 19% less likely to start smoking than peers who were not provided with such information. Compared with other methods such as group sessions to discuss the health risks of tobacco; videos and pamphlets that provided information on tobacco; or even prescription forms preprinted with antitobacco messages, having conversations with health care professionals, either in the doctors’ office or over the phone, appeared to be the most effective.

That’s encouraging for physicians who have long struggled to help adult smokers to quit. “We now know that the smokers that have the most difficulty quitting are the smokers that start in their teenage years and smoke into young adulthood. Those are the smokers that may never be able to quit smoking, and that’s recent data,” says Dr. Len Horovitz, an internist and pulmonary specialist at Lenox Hill Hospital in New York City, who was not on the panel. “It seems incumbent upon pediatricians and internists who have experience with these patients to counsel those patients at exactly that time.”

Rates of cigarette smoking among teens have stalled, but that doesn’t mean they aren’t still using tobacco. Some have switched to cigars, which are less expensive, often flavored, and even crafted to look like cigarettes. While teen tobacco use dropped significantly in the U.S. between the years 1997 and 2003, beginning in the early 2000s, these declines started to reverse as states cut funding for tobacco-control programs. From 2009 to ’11, tobacco use remained steady, with about 1 in 5 high school students using some form of tobacco.

(MORE: Secondhand Smoke Is More Damaging for Teen Girls Than Boys)

Will the USPSTF recommendation help bring tobacco use down again? Already pressured to cover a significant amount of health information in a short office visit, Horovitz says doctors may find it difficult to throw another important health issue into the mix. “There’s counseling on diet, exercise, fastening your seat belt [and] nutrition; and smoking cessation measures are a part of the annual physical too,” he says. To make time for discussions about such lifestyle factors and how they affect their health, Horovitz says he allots an hour for each such visit.

Discussing such lifestyle behaviors, including tobacco use, is easier if doctors and patients have a long-standing relationship that is built on trust and familiarity. “All patients will talk about stress, and I ask questions that are pointed enough that they will volunteer that information. When you take care of a patient over a few years, there is trust and confidence in the doctor-patient relationship, and the patient will be more spontaneous in giving you facts that they might not give a doctor at first or if they don’t have a consistency in who they see,” says Horovitz.

Since not all patients have such interactions with their doctors, the task force also identified some other strategies that could help physicians to help their teen tobacco users to quit. For instance, some cessation programs send reminder text messages to teens’ smartphones, while some states, including New York and Rhode Island, have gone after their wallets by increasing the price of cigarettes. Mass-media antismoking campaigns and laws that target retailers selling cigarettes to underage customers are also effective. In an editorial accompanying the new recommendations, Dr. Michael Steinberg of Robert Wood Johnson University Hospital and Cristine Delnevo of the Rutgers School of Public Health also argue for raising the smoking age from 18 to 21, since that would make it much harder for younger people to purchase tobacco products and therefore discourage them from smoking regularly.

With the new recommendation, doctors are being asked to join antitobacco efforts for teens, based on the latest data that suggests they can have a significant impact on whether or not their young patients smoke. It’s just a matter of finding the time to discuss how smoking and tobacco can affect teens’ health, and making such conversations a priority during the office visit.

Source: Time.com

Maternal Prenatal Smoking and Hearing Loss Among Adolescents.


ABSTRACT

Importance  Although smoking and secondhand smoke exposure are associated with sensorineural hearing loss (SNHL) in children and adults, the possible association between prenatal smoke exposure and hearing loss has not been investigated despite the fact that more than 12% of US children experience such prenatal exposure each year.

Objective  To investigate whether exposure to prenatal tobacco smoke is independently associated with SNHL in adolescents.

Design  Cross-sectional data were examined for 964 adolescents aged 12 to 15 years from the National Health and Nutrition Examination Survey 2005-2006.

Participants  Participants underwent standardized audiometric testing, and serum cotinine levels and self-reports were used to identify adolescents exposed to secondhand smoke or active smokers.

Main Outcomes and Measures  Prenatal exposure was defined as an affirmative parental response to, “Did [Sample Person’s Name] biological mother smoke at any time while she was pregnant with [him/her]?” Sensorineural hearing loss was defined as an average pure-tone hearing level more than 15 dB for 0.5, 1, and 2 kHz (low frequency) and 3, 4, 6, and 8 kHz (high frequency).

Results  Parental responses affirmed prenatal smoke exposure in 16.2% of 964 adolescents. Prenatal smoke exposure was associated with elevated pure-tone hearing thresholds at 2 and 6 kHz (P < .05), a higher rate of unilateral low-frequency SNHL (17.6% vs 7.1%; P < .05) in bivariate analyses, and a 2.6-fold increased odds of having unilateral low-frequency SNHL in multivariate analyses (95% CI, 1.1-6.4) after controlling for multiple hearing-related covariates.

Conclusions and Relevance  Prenatal smoke exposure is independently associated with higher pure-tone hearing thresholds and an almost 3-fold increase in the odds of unilateral low-frequency hearing loss among adolescents. These novel findings suggest that in utero exposure to tobacco smoke may be injurious to the auditory system.

Source: JAMA

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 Smokers Quit Abruptly or Gradually?.


Quit rates are roughly the same, and relatively poor, with both approaches.
The main approaches to quitting smoking are abrupt cessation (sometimes called “cold turkey”) and gradual reduction of smoking before quitting. U.S. clinical practice guidelines, as well as pharmaceutical labels required by the U.S. FDA, strongly imply that smokers should try to quit smoking abruptly as part of various quit regimens. However, some smokers prefer to gradually decrease their nicotine intake. In a Cochrane review of 10 randomized controlled trials conducted in various clinical settings in several countries, researchers assessed quit rates at least 6 months postintervention (gradual reduction or abrupt cessation) in 3760 smokers who wanted to quit smoking. Smoking status was verified biologically in 7 studies.

Quit rates were 14% to 15%, regardless of cessation approach. The success of either approach did not differ in studies that incorporated nicotine replacement, self-help methods, or behavioral support.

COMMENT

In this meta-analysis, quit rates were similar for abrupt cessation and gradual reduction of smoking before quitting. These results suggest that clinicians can work with patients who want to quit smoking to identify which approach they prefer, as part of a comprehensive smoking cessation program. Clinical practice guidelines in the U.S. favor abrupt cessation, but those in the U.K. and Australia already incorporate this flexibility.

Source: NEJM