Legal but Lethal
CHOCOLATE-FLAVORED NICOTINE Taming the “Wild West” of Electronic Cigarettes Robert K. Jackler, MD Over the past few years, electronic cigarettes (eCigs) have burst into the American consciousness. They
were invented in China in 2004 and were introduced to the U.S. market in 2007. What was formerly confined to a small, youthful subculture is now receiving enormous media attention, including a recent series of front-page New York Times articles. The technology comes in three sizes: eCigs about the size of typical cigarette; vape pens, which are favorites for delivering marijuana extracts; and the large ehookahs or “hoses.” While still a small fraction of the U.S. combustible cigarette market, at $1.8 billion in 2013, sales are tripling every year and some analysts predict that eCigs may exceed conventional tobacco products within a decade. The eCig market is populated by hundreds of start-up companies, most of whom simply stick their label on one of a mere handful of device types emanating from China. This early entrepreneurial phase is now transitioning to a more mature market in which the major tobacco companies (Lorillard-Blu, RJ Reynolds-Vuse, and Altria-Mark Ten), with their vast marketing resources and immense distribution systems, are asserting dominance. Rather than smoking, eCigs uses are said to be “vaping.” The devices vaporize a liquid known as “ejuice” or “eliquid,” which contains a mixture of propylene glycol and glycerin together with flavoring and variable concentrations of nicotine (from 0 to 36 mg per ml). Brands compete to create the most impressive plume, with some devices generating impressive clouds several feet in length. Some eCigs strive to emulate the look and feel of a regular cigarette (e.g., NJOY), while others proudly differentiate themselves by distinctive designs (e.g., Blu). All eCigs have three major components: a chamber containing ejuice, a heating coil to atomize it, and a lithium ion battery. When the user draws vapor, a light illuminates at the tip. Sometimes the tip glows orange to simulate a lit cigarette, while others use fanciful colors. Some eCigs are single-use disposables while others are rechargeable and employ replaceable eliquid cartridges. Technologically sophisticated systems include chargers, USB interfaces, Bluetooth connectivity, and even smartphone apps to record usage and order supplies. The business model is similar to inexpensive computer printers: a cheap device with profit residing in costly refills of proprietary liquid cartridges. As physicians, we would prefer that people not smoke. Studies show that adult smokers try eCigs out of a desire to quit smoking entirely. From a public health perspective, the hope is that eCigs would prove effective as nicotine cessation devices, or at least be a less harmful replacement for combustive cigarettes. As of mid-2014, scientific data is sparse on both accounts. Disappointingly, a recent study from UCSF showed no tobacco cessation effectiveness, while a British study showed that eCigs 14
worked roughly twice as well as patches, but still well under 10 percent efficacy.1,2 Most experts believe that if a cigarette smoker transitions entirely to eCig use, it is likely to reduce health risk. One reason is that the carcinogenic fraction of cigarettes derives primarily from the products of leaf combustion. While one might speculate that eCigs are a safer alternative, they are almost certainly not safe. The effects of inhaled nicotine have been extensively studied, but little is known about the long-term effects of breathing copious amounts of aerosolized propylene glycol and glycerine into alveoli. Chronic inhalation of large quantities of flavorants made of aldehydes, ketones, and other chemicals is also of concern. Eosinophilic pneumonia from eCigs has been reported and, over the long term, we may recognize a pattern of eCig-caused pulmonary diseases. A big problem with weaning adult smokers from regular cigarettes is the dual-use phenomenon. Discontinuities of nicotine dosing helps smokers quit. Today smoking is widely prohibited in work places, restaurants, bars, public parks, airports, etc.
SAN FRANCISCO MEDICINE JULY/AUGUST 2014 WWW.SFMS.ORG