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Vol. LXVII, No. 15
July 17, 2015

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E-Cigarettes: Are Advocates Just Blowing Smoke?

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Dr. Stanton Glantz of UCSF speaks at NIH.

Dr. Stanton Glantz of UCSF speaks at NIH.

Debates are heating up about electronic cigarettes. Proponents claim these “e-cigs” are less toxic, offer a safer alternative to smoking conventional cigarettes and may even help longtime smokers kick their habit altogether. But their utility and safety remain clouded in controversy. Are e-cigs really any safer for people and the environment?

E-cigarettes are battery-operated devices that heat a chemical solution and produce an aerosol. There are many different kinds—disposable, rechargeable, refillable, larger vapor pens that burn much hotter—many of which contain nicotine, formaldehyde and other carcinogens. The vapor of chemicals gets inhaled then released into the air.

The aerosol from e-cigs contains ultrafine particles—more and tinier particles than cigarettes—that penetrate the body and can pose a health risk. “These particles trigger inflammatory processes…they go very deep into your lungs; they go right across the alveoli into your bloodstream and they’re carrying all of these chemicals with them,” said Dr. Stanton Glantz, a distinguished professor at the University of California, San Francisco, School of Medicine.


Of e-cigarette use, Glantz noted, “I think bathing your gums in a hot propylene glycol aerosol of nicotine and heavy metals is probably not good for you.”

Of e-cigarette use, Glantz noted, “I think bathing your gums in a hot propylene glycol aerosol of nicotine and heavy metals is probably not good for you.”

Photos: Rich McManus

He spoke at a recent NIDCR Clinical Research Fellowship Grand Rounds at Porter Neuroscience Research Center, just as the institute was announcing a call for research applications on the oral effects of e-cigs. Admittedly not an expert on dental health, Glantz said, “I think bathing your gums in a hot propylene glycol aerosol of nicotine and heavy metals is probably not good for you.” He lauded the RFAs to study the oral health impact, one of many areas in which more research on e-cigs is needed.

“In the current regulatory environment, the main danger of e-cigarettes is that they keep people smoking cigarettes,” said Glantz. While some people may successfully quit smoking with the help of e-cigs, he said, those people are in the minority. “[Among all smokers], e-cigarettes are not only not helping people quit, they’re actually inhibiting quitting.”

Multiple studies have shown that, overall, people who use e-cigs are about one-third less likely to quit smoking, said Glantz. Many smokers who use e-cigs to try to quit smoking wind up dual users, alternating between e-cigs and cigarettes. Contributing to this dual-use effect, e-cigs are not yet prohibited in many smoke-free areas, although this situation is changing, particularly through local government action.

“Smoke-free environments are a powerful motivator and assist in quitting smoking,” said Glantz. “If you have an alternative nicotine device that you can use in places where you can’t smoke cigarettes,” that makes it even harder to quit. For people trying to quit smoking, he added, “you’re better off using FDA-approved medicines and counseling.”

Another factor inhibiting quitting, said Glantz, is the deceptive advertising and marketing. Much as early cigarette ads made smoking look trendy, glamorous and cool, e-cigarette ads tout similar messages, emphasizing e-cigs as a healthier choice while giving the impression it’s once again socially acceptable to smoke. After all of the progress made by smoking ad restrictions and clean air laws, Glantz said, e-cigs may have the harmful effect of renormalizing tobacco use. That was why his talk was sub-titled, “Back to the Future.”

E-cigarette sales started out as a small, niche market in specialty shops. But as the major cigarette companies have entered the business, e-cigs are now mass marketed, sold in gas stations and convenience stores, often next to candy or medicines. Almost all e-cigs are flavored, which contributes to their wide appeal with kids.

In fact, e-cig use has dramatically risen among children and young adults and is associated with the progression to established smoking. In one recent cross-sectional study using National Youth Tobacco Survey data, said Glantz, kids who experimented with cigarettes (smoking at least one puff) and who also used e-cigs were almost 8 times more likely to become conventional smokers than kids who never tried e-cigs.

“Nicotine, despite what the cigarette companies say, is not like caffeine. It’s a neurotoxin; it changes your brain and your nervous system,” said Glantz. “And it’s very well established that the younger kids are when they start using nicotine, the more heavily addicted they get, the longer they use and the harder time they have quitting.”

E-cigarette advocates often focus on the lower cancer toxicity profile, but epidemiological studies show the duration and amount smoked may be just as much a factor as the intensity. “If that turns out to be the case, the fact that levels of carcinogens are lower may be less important,” said Glantz.

Studies show that most smokers are killed not by cancer but by heart disease and non-cancer lung disease, said Glantz, who has done extensive research on the cardiovascular effects of tobacco. “E-cigarettes do deliver fewer carcinogens than conventional cigarettes, but they have a toxicological profile which I think is going to be very high risk for cardiopulmonary disease.”

There’s also the issue of secondhand smoke. E-cigs don’t smolder like cigarettes, but they do release ultrafine particles, nicotine and other toxins that pollute the surrounding air and are absorbed by bystanders.

One argument for e-cigarettes and harm reduction in general has been that there are hard-core tobacco smokers who cannot quit or refuse to even try. But U.S. surveys over the last 18 years show that smoking prevalence and consumption are declining while quitting is on the rise, which shows softening, not hardening, of the remaining smoking population. Said Glantz, “The tobacco control strategies we’ve been using—clean indoor air laws, strong media, increased taxes, restrictions on sales—are working and we’re pushing the population down that curve. I think that’s what we should just keep doing.”

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