e-Cigarette Research: Smokin' Hot, Controversial

Pauline Anderson

June 17, 2014

Electronic nicotine delivery systems, commonly known as e-cigarettes, are fast becoming one of the hottest and most controversial research topics.

Three new studies from the Institute for Health Research and Policy, University of Illinois, in Chicago, show that e-cigarettes are increasing in popularity, that they are becoming increasingly available in stores frequented by youth, that regulation of these products is lagging behind their growing use, and that they are highly sensitive to price increases.

The research, part of the State and Community Tobacco Control Program, funded by the National Cancer Institute, was published online June 17 in a special issue of Tobacco Control.

These and other related studies reflect an emerging debate that is dividing the research community, according to experts. On one side are those who argue that e-cigarettes are just a way for Big Tobacco to market them as a gateway to other tobacco products. On the other side are those who believe e-cigarettes are a healthier alternative to traditional cigarettes and could mean an enormous reduction in healthcare costs.

An author on all 3 of the new articles, Frank J. Chaloupka, PhD, distinguished professor of economics and director, Health Policy Center, at the University of Illinois, said that he is somewhere in the middle of the debate.

"There's potential for lot of good and potential for lot of harm" with e-cigarettes, Dr. Chaloupka told Medscape Medical News. "I think some balance of regulation that limits marketing of e-cigarettes and limits kids' access to them is the most appropriate thing to do."

Most e-cigarettes fall into 3 broad categories: cigarettelike devices; medium-sized pen-style cigarettes known as "e-hookahs," "hookah-pens," or "vape pipes"; and large tank-sized devices known as advanced personal vaporizers.

There are disposable versions of e-cigarettes that are thrown out once the battery is drained or the liquid, which contains a variable amount of nicotine, is exhausted. Reusable devices come with refillable cartridges, some with different flavoring, such as banana and chocolate.

Increased Availability

One of the new studies that is reported in Tobacco Control found that e-cigarettes are increasing in availability and can now be found in about a third of US tobacco retailers. The availability of e-cigarettes increased from 3% in 2010 to 7% in 2011 and to 31% in 2012, the authors note. These products tend to be more widely available in stores that derive a higher proportion of revenue from tobacco product sales, they add.

The study also showed that e-cigarette availability appears more likely in areas with weak tax and smoke-free air policies.

"Where they are available has changed over time," said Dr. Chaloupka. "A few years ago, people were buying them mostly online and in kiosks in malls, but they have become more available in the same places that sell traditional cigarettes, so convenience [stores], grocery stores, and other places where kids shop."

The more available e-cigarettes become, the more "normative" they appear to kids, he added.

A second study examined state laws governing e-cigarettes and found a variable and changing landscape. Currently, e-cigarettes are not regulated by the US Food and Drug Administration (FDA), although the FDA has indicated that it intends to regulate them as a tobacco product, not as a drug or delivery device. This impending regulation should not supersede existing state or local e-cigarette laws.

The research showed that 34 states have laws regulating e-cigarettes or tobacco-derived products. Of these, 28 laws apply to e-cigarettes, all of which have been adopted since 2009. These state laws exist largely within the areas of youth access (22 states) and smoke-free air (12 states) laws. Only 1 state, Minnesota, explicitly applies excise taxes to e-cigarettes.

Minnesota's law has a fairly broad definition of a tobacco product, inasmuch as it includes basically anything that contains nicotine derived from tobacco, said Dr. Chaloupka.

"Most states laws are not comprehensive," the authors note. "This means that e-cigarette use has the potential to undermine the very same clean indoor air environment that SFA [smoke-free air] laws are designed to protect, and to enable minors to access and use e-cigarette products that may contain nicotine and other harmful ingredients.

"Opportunities exist for states to expand their existing laws to apply to e-cigarettes, which is important, given recent reports that e-cigarette use and awareness are growing steadily."

State laws are "kind of lagging behind the increase in availability and increase in use" of e-cigarettes, added Dr. Chaloupka. "A lot of states haven't figured out how to deal with them under their youth access policy," and kids in many states can purchase them without restrictions.

Price Responsiveness

The third study showed that price is a key determinant of the sales of e-cigarettes. A 10% increase in price reduces sales of disposable e-cigarettes by about 12% and reduces sales of reusable e-cigarettes by about 19%. This, say the authors, suggests that policies altering e-cigarette retail prices, such as limiting rebates, discounts, and coupons and imposing a tax, could lead to significant reductions in use.

"e-Cigarette sales are much more responsive to price than traditional cigarettes, and part of the reason for that is that people are still experimenting with them," said Dr. Chaloupka. So whereas a long-time smoker of traditional cigarettes might not quit smoking when a package of his favorite brand goes up a nickel, this might not be the case with e-cigarettes.

He pointed out that kids may be particularly responsive to price increases from such things as taxes.

Although prices vary across states, a disposable e-cigarette in New York might cost about $10, which is about equivalent to the price of 2 packages of traditional cigarettes, said Dr. Chaloupka. This, he said, delivers as much nicotine as smoking 4 packs of tobacco-filled cigarettes.

Dramatic Increase in Use

Commenting on the articles for Medscape Medical News, Jasjit S. Ahluwalia, MD, executive director, Center for Health Equity, and associate director, Clinical and Translational Sciences Institute, at the University of Minnesota Medical School, in Minneapolis, said the research "is sort of a case study in sociology, business, marketing, regulation, science, nicotine."

Stop-smoking aids began with nicotine gum and expanded to the nicotine patch, inhalers, sublingual tablets, and then to drugs such as bupropion and varenicline (Chantix, Pfizer Inc).

"Then someone smart came up with the idea of getting something that looks like a cigarette and is used like a cigarette, but with the bad things taken out, and just leaving the nicotine in it," said Dr. Ahluwalia.

He added that he has been struck by the dramatic increase in e-cigarette consumption. It is now a $2 billion industry in the United States and a $3 to $4 billion industry worldwide, he said. And although jurisdictions in Europe are "coming down hard" on regulating or banning e-cigarettes, the FDA "is like a deer in the headlight," he said.

One of the current issues is whether e-cigarettes pose a health threat to youth. Dr. Ahluwalia noted that they contain nicotine, which is "probably" harmful to the developing brain in young teens and "definitely" harmful to the developing fetus, and is "somewhat" dangerous in high doses for heart patients.

There is no question that kids love experimenting with new gimmicks and that given the opportunity, they will try e-cigarettes. "The question is," said Dr. Ahluwalia, "does it become an addiction to e-cigarettes or does it become a gateway drug, so to speak, to actual tobacco use, and we don't know the answer to that."

In any case, he added, "it is definitely a lot safer than traditional cigarettes," although there are no data to show that e-cigarettes help people stop smoking.

In Dr. Ahluwalia's opinion, e-cigarettes should not be sold to anyone younger than 18 years, and manufacturers should not be allowed to make health claims about them, such as their being safe or an aid to quitting smoking, unless such claims are validated by science.

But these products could serve a useful purpose as smoking cessation aids and in so doing save healthcare costs, said Dr. Ahluwalia. To completely ban them, he said, would be "a tragedy."

It is possible, according to Dr. Ahluwalia, to purify the nicotine in an e-cigarette, to clearly label it with exactly how much nicotine it has, to verify that it contains no carcinogens, and to regulate it.

Dr. Chaloupka and Dr. Ahluwalia reports no relevant financial relationships.

Tob Control. 2014;23:iii10-iii17, iii37-iii40, iii41-iii47. Full article, Full article, Full article

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