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Oncology Times:
doi: 10.1097/01.COT.0000438509.26984.26
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AACR News Briefing Highlights Challenges in Evaluating and Regulating Electronic Cigarettes

Eastman, Peggy

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Concerned about the rapidly escalating popularity of electronic cigarettes and the many unknowns surrounding their possible health effects, the American Association for Cancer Research held a news briefing as part of its Frontiers in Cancer Prevention Research International Conference to explore issues related to these products.

An e-cigarette is a smokeless electronic device that typically uses a heating device to deliver a vapor of liquid nicotine that, when it is inhaled, imitates smoking—but without the tobacco. According to the statistics cited, about six percent of American adults have tried e-cigarettes, whose sales are expected to approach $2 billion this year. On the one hand, the AACR panelists said, public health officials don't want to squash sales of e-cigarettes if they can help tobacco smokers quit, but on the other hand they don't want to risk health damage due to as yet unknown harmful effects of these popular products, especially in the young.

The U.S. Food and Drug Administration is now considering how best to regulate these products, which are often appealingly flavored like candy and are attractive to children and teenagers. While federal law forbids the sale of tobacco cigarettes to minors, there is no such age restriction on sales of e-cigarettes. One option for the FDA: ban online sales of e-cigarettes.

“It seems like we're in the midst of a national and international experiment” in the use of e-cigarettes since their health effects—especially long-term—are largely unknown, said Scott Leischow, PhD, Co-Lead of the Cancer Prevention and Control Program at the Mayo Clinic in Scottsdale, Arizona. “This is sort of a Wild West phenomenon, especially in social media. ... A dramatic amount of more research is needed and needed very soon.”

SCOTT LEISCHOW, PHD
SCOTT LEISCHOW, PHD
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To date, though, he noted, the health risks of e-cigarettes do appear to be much lower than those from smoking tobacco cigarettes.

On the up side, e-cigarettes can suppress withdrawal symptoms such as nicotine craving in those trying to quit tobacco. Also, Leischow said, when used by people trying to quit smoking, e-cigarettes increase public awareness that smoking tobacco is harmful.

He pointed out that the vast majority of U.S. adult tobacco smokers today are low-income, those who can least afford medically approved smoking-cessation services. And, for some tobacco smokers, going through a “conversion” process from tobacco cigarettes to e-cigarettes is psychologically easier than simply quitting. “The notion of switching is cognitively very different from quitting,” he stressed.

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‘Gateway’ to Tobacco Cigarettes?

As for whether e-cigarettes are a “gateway substance” for tobacco cigarettes, Leischow said, “That is a very low probability” based on the limited data he has seen. But, asked by OT whether adolescents, who are known experimenters and thrill seekers, might not want to move from e-cigarettes to tobacco cigarettes, Leischow said, “It is far too soon to suggest that it can't be a gateway or won't be a gateway. I don't think any of us would suggest that nicotine is a safe product.”

E-cigarette products “are changing so rapidly” that they are going to be a real regulatory challenge for FDA, he said.

Also speaking at the briefing, Peter Shields, MD, Professor and Deputy Director of Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, said, “Kids start smoking for lots of reasons: It's considered cool, and teenagers are especially susceptible to peer pressure. If it's that much like a cigarette, we may be playing with fire.”

If e-cigarettes are indeed harmful, he said, “we don't want college students to smoke e-cigarettes and normalize this behavior.”

Shields said he recommends to his patients who are trying to stop smoking that they try approved, established, evidence-based smoking-cessation methods first, such as using a nicotine patch. As for e-cigarettes, he said, “I won't discourage them, but I'm generally not encouraging them. ... Let the FDA do its job, and we'll figure it out.”

PETER SHIELDS, MD
PETER SHIELDS, MD
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‘Huge Variability’

There is a “huge variability” in e-cigarettes in terms of possible toxic exposures, said Maciej Goniewicz, PharmD, PhD, Assistant Professor of Oncology in the Department of Health Behavior at Roswell Park Cancer Institute. He agreed that for some tobacco smokers who are trying to quit cigarettes, e-cigarettes can provide benefit. But Goniewicz said that in studying the vapor of some e-cigarettes, he has found some toxicants and even carcinogenic substances.

For example, some e-cigarettes contain propylene glycol and other chemicals; there are unanswered questions about the possible long-term risk of inhaling propylene glycol. However, he said, if there is benefit to tobacco smokers who switch to e-cigarettes to stop smoking, “I believe we cannot ignore this.”

For this reason, he said he does not want the FDA to over-regulate e-cigarettes. He said what is needed is research showing the efficacy of e-cigarettes in helping smokers of tobacco cigarettes quit relative to other established smoking-cessation methods. In this regard, studies on what is actually in e-cigarettes are urgently needed, he said, adding, “Hopefully we will get more and more information.”

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Earlier Comments from ACS and MD Anderson

The American Cancer Society has not taken a position on e-cigarettes, such as whether they should be banned from the U.S. marketplace. However, the ACS has stated, “Electronic cigarettes are designed to deliver nicotine, and nicotine is an addictive substance. This strongly suggests that e-cigarette use will lead to dependence, unless the user weans him or herself from them.”

Officials at MD Anderson Cancer Center are strongly on record as warning the public about the potential dangers and risks of e-cigarettes. “We've been telling society for the past 30 years that they shouldn't smoke, and that tobacco is bad,” said Paul Cinciripini, PhD, Director of MD Anderson's Tobacco Treatment Program, in a statement released in August.

MACIEJ GONIEWICZ, PHARMD, PHD
MACIEJ GONIEWICZ, PHARMD, PHD
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PAUL CINCIRIPINI, PHD
PAUL CINCIRIPINI, PHD
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“But tobacco companies are smart and have a good marketing strategy when it comes to promoting new products. Promoting the e-cigarettes already on the shelves as ‘safe’ is misleading and, if looked at as a harmless alternative to cigarettes, could potentially lead to a new generation of smokers more likely to become tobacco dependent.

“There is not enough research involving e-cigarettes for us to really know what's in them such as added components that could be potentially harmful.”

Alexander Prokhorov, MD, PhD, Director of MD Anderson's Tobacco Outreach Education Program, said in the same statement: “Because they contain nicotine, e-cigarettes can indeed be a gateway for children and youth in switching to tobacco products. What looks cool and attractive can be an illusion, especially to children and teens who are easily impressed. We must be proactive in educating our communities, schools, and government about dangers associated with these products.”

The National Association of County and City Health Officials (NACCHO) is sufficiently concerned about the potential risks of e-cigarettes that it urged the FDA to enact strict regulations overseeing the use and sale of these products, and to conduct research on the health effects.

Among its specific requests, NACCHO wants the sale of e-cigarettes to minors prohibited; online and mail sales of these products banned; stiff excise taxes on e-cigarettes, similar to those on tobacco cigarettes; and restrictions on where e-cigarettes can be sold in the community.

Wolters Kluwer Health | Lippincott Williams & Wilkins

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