WHILE GREAT STRIDES have been made in decreasing traditional cigarette smoking in the United States, a new danger is poised to reverse this advance in disease prevention. Electronic cigarettes (e-cigarettes), also known as electronic nicotine delivery systems, have saturated the market in recent years. Nicotine is once again being made to look sexy, smart, and glamorous. The renormalization of smoking by this new technology exposes more individuals to nicotine and increases their risk for addiction and other health consequences. Efforts to regulate tobacco use are being sidelined by the big business of e-cigarettes.
Advertisers claim that e-cigarettes are merely a means to quit smoking by delivering nicotine, a tobacco derivative, through a process known as vaping, although evidence supporting this proposed benefit is scant. In spite of this, in 2014, vape, defined as the inhalation and exhalation of vapor through a device such as an e-cigarette, was named the Oxford English Dictionary word of the year.1
This article presents some of the dangers of e-cigarettes, examines their potential usefulness in tobacco cessation efforts, and discusses new legislation aimed at regulating these products.
Young children, teens, and college-age youth who experiment with vaping may find themselves fighting a strong addiction to nicotine later on in adulthood. The highly addictive nature of nicotine is a critical element when an experimental tobacco smoker transitions to a sustained habit of cigarette smoking.2 Although e-cigarettes don't contain tobacco, they may contain tobacco-derived nicotine. A global survey of over 19,000 e-cigarette users found that less than 4% of them choose products that don't contain nicotine.3
More than 250,000 youth who've never smoked traditional cigarettes have tried e-cigarettes.4 Data from National Youth Tobacco surveys estimate that middle and high school students who've used e-cigarettes are twice as likely to smoke traditional tobacco products.4 A recent longitudinal study reports that youth who tried e-cigarettes were more likely to initiate traditional cigarette use over the subsequent year.5
Easy access coupled with flavoring make e-cigarettes especially appealing to children, adolescents, and young adults. As of early 2014, e-cigarette products were available in over 466 brands and 7,764 unique flavors with about 242 new flavors added per month.6,7 Public health strides to reverse the trend of youth tobacco use may be challenged by a product used by celebrities that's viewed as cool.
National reports of e-cigarette products demonstrated a 150% increase since 2012.8 Because Loomis et al. conducted their study before recent federal regulation, it may serve as a baseline measurement for any changes achieved with new legislation.8
Current federal tobacco laws resulted from decades of efforts to protect the public, and particularly children and teens, from smoking. Since early initiatives to curb harm from smoking cigarettes, substantial research has linked smoking to diseases of nearly all organs in the body, to harm to the fetus, and to overall morbidity and mortality.2 Although e-cigarettes are heralded in the lay media as a smoking cessation tool and can be easily purchased on the Internet, current research can't be used to predict the long-term effects or potential harm of e-cigarette use.9,10
In May 2016, the FDA extended its authority to include regulation of e-cigarettes that contain tobacco products and nicotine.11 The new regulations require product manufacturers to:
- list the ingredients in all e-cigarette products
- place health warning labels on all product packaging and ads
- register manufacturing establishments
- prohibit the sale of modified-risk tobacco products (including e-cigarettes, cigars, hookahs, pipe tobacco, nicotine gels, and dissolvable products that didn't previously fall under the FDA authority)
- prohibit sales to those under age 18, sales in vending machines except in adult-only venues, and distribution of free samples
- undergo a premarket review to receive marketing authorization.2,12
Examine the evidence
Before the FDA's 2016 ruling, concerns about the regulation of e-cigarette use had reached a fever pitch. The debate highlighted the controversy about the use of e-cigarette devices: Do they offer an acceptable alternative for smoking cessation or do they perpetuate smoking? Only two randomized controlled studies looking at the use of e-cigarettes as a smoking cessation tool have been published to date. Both demonstrated statistically insignificant evidence that the use of e-cigarettes improved rates of sustained smoking cessation.13,14 Both trials recommended further study. In a systematic review of 27 case reports about individuals using e-cigarettes, negative outcomes (such as systemic effects, nicotine poisoning, and mechanical effects) were reported in 25.15
The issues of e-cigarettes should prompt the public health community to gather all available evidence on their potential harm as well as their proposed benefits. Ethical implications for healthcare providers include addressing patient needs and lifestyle choices while refraining from promoting a product that may cause future harm.
The availability of e-cigarettes in retail outlets in the United States is more prevalent in communities with a higher median household income and lower percentage of minority residents.16 This is in contrast to low-income communities, which have the highest numbers of traditional smokers.17 E-cigarettes are marketed to young people, who aren't those most in need of smoking cessation efforts. Prior Federal regulations strictly prohibited this marketing practice. Data from a nationally representative sample of teens suggest that one of the biggest reasons teens vape is based on taste.18 Youth with increased access to e-cigarettes and a variety of flavors to choose from should raise some red flags for healthcare clinicians.4
Looking at the chemicals
E-cigarettes, which are powered by a battery, produce a vapor by heating a humectant such as propylene glycol mixed with flavorings and/or nicotine that activates when the user inhales.19 (See Anatomy of an e-cigarette.) Most users choose a nicotine product when vaping.10 While many products resemble a traditional cigarette, others resemble pipes, pens, or lipstick.19 Researchers question the quality control used in manufacturing e-cigarettes and the potential impact of inhaling aerosolized propylene glycol, the main chemical component in some products, as well as additional additives.15
The potential use of nicotine in e-cigarette products highlights the problem of nicotine addiction. The varying nicotine levels in different brands and unknown chemical components used remain untested and unclear.20
Many advocates of e-cigarettes believe that their harms are overstated. They argue that the cost-benefit equation should take into consideration these products' value as alternatives to smoking traditional cigarettes, saving long-term healthcare dollars spent on tobacco-related illness and death.21 Because e-cigarettes don't contain tobacco, they're purported to be “less toxic” than traditional tobacco products, but the lack of long-term research and the variability among available products makes this claim unsubstantiated to date.10 Additionally, the overall cost savings of substituting smokeless tobacco products to decrease negative health outcomes of traditional tobacco products is still unknown.
E-cigarettes have been treated as a single product for research purposes, but further investigation demonstrates increasing variability among products.20 Overgeneralizing about a product that may be beneficial in tobacco control in some of its forms could be dangerous because the long-term effects aren't yet realized.
A role in tobacco harm reduction?
In 2006, the American Council on Science and Health endorsed tobacco harm reduction (THR), defined as “actions taken to lower the health risks associated with using tobacco or nicotine.”22,23 (See Goals of THR.) THR supporters contend that substituting safer sources of nicotine will help smokers who can't or won't stop smoking and that these smokers are less likely to develop complications associated with tobacco use.23
THR using e-cigarettes has been proposed as one of the more favorable options for harm reduction because of its acceptability by smokers.9 Even the American Heart Association (AHA), in a policy recommendation, states that supporting smoking cessation attempts with e-cigarettes is “reasonable” for those patients who've failed conventional treatment or refuse to use smoking cessation medication.6
How this particular viewpoint will play out in the form of national policy guidelines is unclear. However, the latest U.S. Preventive Services Task Force recommendation concludes that evidence is insufficient to recommend the use of e-cigarettes as a tobacco cessation alternative.24
Advocates for stricter regulation of e-cigarettes suggest a different view on harm reduction. Their increasing concern is that the public opinion of smoking has softened and the acceptance of e-cigarettes will reverse efforts to date to decrease smoking overall.24 Tobacco companies have acquired some e-cigarette manufacturers, raising other concerns25: In the past, tobacco went unregulated for many years, largely due to the influence and lobbying efforts of tobacco corporations.26
With the new FDA regulations, history may repeat itself. The costly premarketing application process will undoubtedly leave only the biggest manufacturers—the tobacco companies—to market and sell these products.12 Other harms are highlighted by multiple lawsuits related to injuries from using e-cigarettes, including combustion, nicotine poisoning, and systemic effects such as sensory disturbances.27
The AHA, the American Lung Association, and the World Health Organization all support stringent regulatory efforts for e-cigarettes until their safety and efficacy are known.6 Another drawn-out public policy battle may be on the horizon.
Emerging health policy issue
In the not-too-distant past, the tobacco industry manipulated levels of nicotine in cigarettes without the public's knowledge, thereby increasing their potential for causing addiction. This revelation bolstered antismoking advocates across the country.26 Whether the tighter restrictions recently enacted will improve health outcomes in the general public remains to be seen, but they constitute important steps to protect the safety of the nation.
Questions still remain. The public is confused about where e-cigarette use is permitted. Most smoke-free laws were enacted before the introduction of e-cigarettes. Is e-cigarette use permitted where tobacco cigarette use is not? The health impact of exposure to secondhand vapor isn't known, and little legal guidance exists on this topic. Additionally, the scope of state and local laws varies and are only a temporary fix because they fail to provide a uniform national policy for e-cigarettes.19
E-cigarette sales have risen rapidly in the United States, from $195 million in 2011 to over $2 billion in 2015.28 Online sales have surpassed the $1 billion mark.29 These figures raise the stakes dramatically for those invested in the manufacturing and marketing of e-cigarettes. A complex dynamic is displayed by opposing objectives: the possible public benefits of smoking cessation alternatives versus potential future harm from e-cigarettes. The evidence-based recommendations surrounding e-cigarette use encompass four key components: inadequate safety, poor effectiveness, minimal regulation, and an ethical framework that proposes to do no harm.30
Now that the new FDA regulations have been initiated, healthcare professionals should guide patients based on current regulatory standards and best practices supported by well-designed research studies. Currently, 85 ongoing research projects are focused on e-cigarette use. Their results will help policymakers form reliable evidence-based recommendations going forward.12
Nicotine addiction is considered a tobacco use disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).31 Nurses are on the front lines, educating and promoting smoking cessation efforts to the public, and they must be well-informed of the harms and benefits associated with any suggested alternative to traditional tobacco use. Current research implies that nurses' lack of knowledge of the available resources to assist patients to stop smoking may hinder their efforts to conduct successful smoking cessation interventions.32 Promoting awareness of the potential harms of e-cigarettes among nurses involved in smoking cessation efforts is an important first step toward improving current strategies to mitigate the challenges from increasing availability and use of e-cigarettes.
Healthcare clinicians' recommendations should be reserved for strategies demonstrated to be safe and effective for patients who wish to quit smoking. These strategies include nicotine replacement therapy such as patches, gum, and inhalers; medications such as sustained-release bupropion hydrochloride, varenicline, clonidine, and nortriptyline; and counseling, support groups, and various online resources.33 Primary prevention and avoidance of tobacco products in general is an optimal health goal. The protection of youth and limitation of their access to e-cigarettes should be a national priority.
Policies and public opinion have increased restraints on traditional cigarette smoking over the years.25 Sustaining the momentum of important public health advancements while guiding the public with sound evidence-based recommendations remains a core objective for healthcare clinicians today.
Nurses are particularly well-positioned to address smoking cessation efforts. For example, a growing body of evidence shows that nurses can play a key role in the public health efforts toward smoking cessation.32,34 One thing remains clear in the search for viable options to help with smoking cessation: Patients need evidence-based, reliable, and effective solutions. Civil libertarians, lobbyists, medical professionals, and the public will continue to sound off in the coming months as the new regulations take shape. Nurses must make sure that, as healthcare professionals and key stakeholders in this debate, we have the loudest voice.
Anatomy of an e-cigarette
Most e-cigarettes consist of three different components, including a:
- cartridge, which holds a liquid solution containing varying amounts of nicotine, flavorings, and other chemicals; some are nicotine free
- heating device (called an atomizer or a vaporizer)
- battery (or sometimes another power source).
In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting aerosol or vapor is then inhaled (called “vaping”).
Goals of THR35
- Lower the smoking rate by offering an acceptable substitute to traditional cigarettes.
- Provide a safer alternative to traditional cigarette smoking.
- Provide an incentive for smokers to use a less harmful product.
- Reduce initiation of traditional cigarette smoking.
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