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Tuesday, Sept. 2, 2014

The Pros and Cons of E-Cigarettes

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Last week, the World Health Organization (WHO) took the bold step of asking for new regulations on e-cigarettes, tobacco-free electronic devices that have become wildly popular in the past few years.

WHO recommended bans for use of e-cigarettes in indoor areas because it believes that these devices and the vapor they produce are harmful to users and bystanders. The WHO has also called for bans on their advertising and sale to minors since they could induce kids who aren’t attracted to traditional cigarettes to become hooked on nicotine.

But are the WHO’s health concerns valid?

And will Wisconsin follow WHO’s recommendation and include them in our indoor smoking ban?

Or is vaping e-cigarettes a healthier alternative to smoking traditional cigarettes, one that has no negative public health impact?

 

What’s In Them?

E-cigarettes have been around for about a decade but they’ve exploded in popularity in the past few years. The U.S. Food and Drug Administration (FDA) is now taking steps to regulate them—as well as tobacco products such as cigars, pipe tobacco, hookah tobacco and dissolvable nicotine gels—but e-cigarettes have remained free of any oversight since their inception.

E-cigarettes’ boom is so new that when Wisconsin passed its Smoke-Free Air Law in 2010, “it wouldn’t have occurred to anyone to include them in the law,” said Dona Wininsky, the director of public policy and communications for the American Lung Association of Wisconsin.

Fast-forward to 2014 and vaping is commonplace as e-cigarette sales have skyrocketed. Major tobacco companies have jumped into the market—even though these devices look like traditional cigarettes and deliver nicotine but contain no tobacco. They’re also able to skirt indoor smoking bans in some places and are seen as less harmful than traditional cigarettes.

Hartland, Wis., is home to Johnson Creek Enterprises, the first and largest American manufacturer of “e-liquid” or “smoke juice,” and the second largest in the world, founder and CEO Christian Berkey told the Shepherd.

Berkey predicted that the use of e-cigarettes would outpace traditional cigarettes within the next decade.

“The growth is exponential,” Berkey said. “It’s just not stopping.”

The six-year-old company produces all of the smoke juice for Republic Tobacco and has its own line of smoke juice, with a variety of flavors and levels of nicotine—even a juice with no nicotine whatsoever.

Berkey said all of its ingredients are produced domestically and while the company’s formula is proprietary, he said it contains food-grade propylene glycol, vegetable glycerin, flavorings and citric acid.

While e-cigarettes’ smoke juice isn’t regulated by the FDA, that’s about to change. Under the agency’s proposed rule, e-cigarettes would have to register with the FDA, report product and ingredient listings, market new products after FDA review, only make claims of “reduced risk” if there’s science to back it up, and not distribute free samples. Additionally, sales to minors would be banned, health warnings would need to be added and vending machine sales would only be allowed in facilities that never admit youth.

Berkey said he welcomed some of the proposed regulations.

“Individually, all of the ingredients that we use are on the FDA list as OK to consume,” Berkey said. “But I think that what we’re going to see in the next few years is more solid regulation come out.”

While Berkey’s company’s ingredients may be safe to ingest, smoke juice produced elsewhere—specifically, smoke juice made in China—may not be so benign. That’s what concerned the WHO when it raised the alarms on e-cigarettes last week. The WHO’s experts found that e-cigarettes can contain toxins or carcinogens including nicotine, formaldehyde, the heavy metal cadmium or nickel.

Douglas Jorenby, director of clinical services at the University of Wisconsin Center for Tobacco Research and Intervention, told the Shepherd that the limited testing by the FDA showed that smoke juice produced where there are questionable manufacturing quality standards contains at least one contaminant that could harm users. 

“Antifreeze,” Jorenby said. 

Berkey said he, too, is concerned about the smoke juice produced overseas, as well as the products made in the U.S. but with ingredients made elsewhere, especially China.

“It really does worry me,” Berkey said. “Companies that create smoke juice really have to understand just how vital it is that the conditions under which they’re creating these products have to be impeccable. They have to make sure that everything is as safe as possible.”

 

Health Impacts

The contents of e-cigarettes’ vapor is at the heart of the recommended indoor bans. The industry says that there’s nothing harmful in the vapor, but anti-smoking advocates say they are waiting for hard evidence proving that second-hand vaping isn’t a public health issue.

“We have worked hard to establish clean air in the state of Wisconsin,” said Lorraine Lathen of the Wisconsin Tobacco Prevention and Poverty Network. “E-cigarettes certainly work against those goals in terms of the vapors that are produced by e-cigarettes. They aren’t regulated, and they haven’t been proven to be safe.”

Jorenby said that e-cigarettes might be safer than traditional cigarettes, but that isn’t saying much.

“The only real dispute from a public health point of view is that when cigarettes are used as directed do they kill only a third or a half of those who use them?,” Jorenby said. “So when you’re looking at something like e-cigarettes, which have been presented as a potentially reduced-harm type of product, they look really good.”

Berkey said that indoor vaping bans were unnecessary.

“They’re ridiculous, in my opinion,” Berkey said. “They’re not based on real science. They’re based on politics and things like that. They’re not based in reality.”

Since the data on the health impacts of vaping aren’t clear, e-cigarettes’ critics say it’s best to err on the side of caution and prohibit them indoors. Chicago just added e-cigarettes to its indoor air ordinance and Minnesota has banned them from health care facilities and buildings operated by the state.

This spring, state Sen. Glenn Grothman (R-West Bend) introduced a bill that would have exempted e-cigarettes from Wisconsin’s indoor smoking ban. The bill got a hearing but didn’t make it out of committee.

But that bill may not have been necessary, since vaping indoors is legal in Wisconsin—it’s up to the property owner to develop their own policy.

“The law still gives the restaurant or the bar owner the ability to set their own internal policies on things that are not included in the law,” said Wininsky of the American Lung Association.

 

Will They Help You Quit?

Also up in the air is the industry’s assertion that e-cigarettes can help smokers of traditional cigarettes cut down or quit altogether.

Berkey said his company manufactures smoke juice with various levels of nicotine, giving users control over how much they want to inhale, and that many of his customers have quit smoking and started vaping.

Jorenby is studying this phenomenon at the UW, and while the data aren’t finalized, he said that anecdotal evidence indicates that this perception simply isn’t true. Smokers continue to smoke while supplementing e-cigarettes when necessary, he said. At the same time there is other anecdotal evidence that e-cigarettes have slowly weaned smokers from cigarettes by systematically decreasing their consumption of nicotine.

Wininsky noted that e-cigarettes are not a federally approved smoking cessation device and no e-cigarette companies have proven it to be true, either.

“We have a number of methods—pharmaceuticals, nicotine replacement therapies and recommendations that have been thoroughly tested, scientifically vetted by the federal government that we know work,” Wininsky said. “We have free quit lines—1-800-QUIT-NOW—where you can get counseling, which is an important component to quit. We know those things work.”

 

Kids Are Curious

In addition to the potential health impact of e-cigarettes, opponents are also concerned about teens’ attraction to them. Many types of smoke juice contain flavoring that appeals to kids, such as bubble gum or fruit flavors.

“They’re taking a page right out of the playbook of the tobacco industry from days gone by,” Wininsky said. “All of the things that the tobacco industry is now forbidden to do from a marketing and advertising standpoint the e-cigarette industry is now copying them verbatim. The same kind of looks, the same kind of appeal. The same play to the same young audience with the same kind of messaging. It’s all there.”

A report issued last week by the U.S. Centers for Disease Control and Prevention (CDC) found that more than 263,000 teens who had never smoked a cigarette tried e-cigarettes last year, up from 79,000 in 2011. These curious teens were almost twice as likely to intend to smoke conventional cigarettes as those who hadn’t tried vaping, the CDC found.

“They do have this appeal to our youth, because of the flavoring,” Lathen said. “It may be the new social norm to smoke an e-cigarette, that it’s the cool thing to do.”

Berkey said that he agrees that e-cigarettes should not be marketed toward teens and his company tries hard to keep them out of the hands of minors by developing more mature flavors that appeal to adults.

But Lathen said more needed to be done to deter kids and teens from trying e-cigarettes.

“There’s a national goal to create a tobacco-free generation,” Lathen said. “We believe that e-cigarettes, in part, place that in jeopardy.”