With the look and feel of real cigarettes, electronic cigarettes are experiencing a boom in popularity. But as the product's popularity rises, so do the unknowns about its potential impact on public health.
As scientific studies on e-cigarettes attempt to catch up with their popularity, it remains to be seen if the products will be a boon to smoking cessation or a setback toward the goal of cutting out nicotine for good.
E-cigarettes are battery-powered devices that convert nicotine into vapor. The products are sold over the counter and are not subject to the same regulation as actual cigarettes. A 2011 survey showed that about 21 percent of smokers had used e-cigarettes at least once — up from about 10 percent of smokers who took the same Web survey in 2010, according to a Centers for Disease Control and Prevention study published online in February in Nicotine & Tobacco Research. About 7 percent of smokers who received the same survey in 2010 via postal mail also said they had tried e-cigarettes at least once.
The Food and Drug Administration announced in 2011 that the agency plans to propose regulating e-cigarettes as a tobacco product, according to Jennifer Haliski, a public affairs officer for FDA's Center for Tobacco Products. Any product containing nicotine from tobacco, unless marketed for therapeutic purposes, is considered a tobacco product, according to the 2009 court case, Sottera Inc. v. Food and Drug Administration.
However, concrete regulations on e-cigarettes have yet to be issued, as the science is still catching up.
"Further research is needed to assess the potential public health benefits and risks of electronic cigarettes and other novel tobacco products," Haliski said.
Getting regular smokers to quit is a potential public health benefit of e-cigarettes, said Maciej Goniewicz, PhD, an assistant professor of oncology at the Roswell Park Cancer Institute's Division of Cancer Prevention and Population Sciences.
Goniewicz said that so far he sees e-cigarettes being mostly used by regular smokers — rather than first-time smokers — as an alternative to smoking cigarettes, offering another chance to quit after a relapse. Goniewicz is one of five authors of a Nicotine & Tobacco Research study published online in April 2012 that compared nicotine and organic compound vapors of 16 e-cigarette brands available in U.S., United Kingdom and Polish markets. The study found 300 puffs of e-cigarettes labeled as having high nicotine levels delivered 0.5 to 15.4 milligrams of nicotine — considered negligible compared to toxins in regular cigarettes.
However, Goniewicz said there is limited data about whether what is exhaled from e-cigarettes contributes to exposure for people besides the user.
"We know there's almost nothing there compared to cigarette smoke," Goniewicz told The Nation's Health. "But we don't know what's going on after a very long exposure. We need to wait for the studies."
Regular use of nicotine, which is found in tobacco, is not without its own health effects. An addictive substance, nicotine use can lead to increased blood pressure and heart rate as well as nausea, sweating and diarrhea, according to the National Institutes of Health. E-cigarettes are not the only product to deliver nicotine to users. A variety of products are used to provide nicotine to users as a tool for smoking cessation, but such tools are regulated by FDA.
FDA-approved over-the-counter cessation products include nicotine replacement chewing gum, lozenges and skin patches. In addition, FDA regulates prescription drugs that block nicotine's effects on a smoker's brain.
Tim McAfee, MD, MPH, director of CDC's Office on Smoking and Health and an APHA member, said it is reasonably certain that if someone who smoked a pack a day switched completely to e-cigarettes it could represent a benefit to health, but there are still many "caveats and 'buts' around that."
One concern is the use of e-cigarettes in businesses or restaurants to skirt clean air ordinances or indoor smoking bans, McAfee said. Use of e-cigarettes in places with established indoor smoking laws could be a step backward for public health when it comes to air quality, as well as a negative for someone who may have otherwise quit nicotine, he said.
"Someone should not have to go in a restaurant and wonder what's coming out of a plastic device that is completely unregulated," McAfee said. "And we know that nicotine comes out, which is not fair to expose people to in a public space, since nicotine is a psychoactive substance."
In Washington, D.C., two members of the Council of the District of Columbia are not waiting for more studies before proposing regulations.
Councilmembers Yvette Alexander and David Grosso introduced legislation April 9 to classify e-cigarettes as regular cigarettes that are already prohibited in indoor areas in the city.
Alexander, who chairs the Council's Committee on Health, said her council staff told her that they had seen people using e-cigarettes inside city bars and restaurants. On a subsequent trip to a convenience store to find one, a man told Alexander he had searched for the device in a quest to quit smoking, she said.
"These e-cigarettes are marketed in one way in that if you want to smoke you can smoke indoors," Alexander told The Nation's Health. "You can beat the ban by smoking these e-cigarettes, that's one marketing tool."
Alexander noted that e-cigarettes are also touted as an alternative for people trying to quit smoking. However, it is uncertain if they are less addictive than traditional cigarettes.
"Everyone is up in arms that I'm trying to ban the e-cigarettes," Alexander said. "I'm just trying to ban them as the same way tobacco products are banned indoors. If you want to purchase them and smoke them in places where you can smoke tobacco products, that's fine. But we just want to maintain the ban on tobacco products for indoor use."
Another potential public health concern is how the product is marketed toward teens and young adults. According to CDC, teens who use smokeless tobacco are more likely than nonusers to smoke cigarettes, which is a trend CDC's McAfee said he does not want to see replicated with e-cigarettes.
Jennifer Pearson, PhD, MPH, a research investigator at the Schroeder Institute for Tobacco Research and Policy Studies at the American Legacy Foundation, said that e-cigarettes are a novelty product for young adults, along the lines of hookah. Pearson is a co-author of a study on e-cigarette awareness published in the September issue of APHA's American Journal of Public Health.
"It's (seen as) something fun, different you can do when you go out and something you can do in the clubs because you're not going to get kicked out," Pearson said.
E-cigarettes continue to evolve, with new models in the absence of federal regulation. Goniewicz said that rather than limit access to the product, he would prefer that regulations ensure quality and safety and prevent advertising to children.
"My point of view is that we still have cigarettes, and this is the main problem," Goniewicz said.
Nations Health. 2013;43(5) © 2013 American Public Health Association