Other Tobacco Products
Electronic cigarettes, or e-cigarettes as they are more commonly known, are nicotine-delivery devices that sometimes look like cigarettes in shape, size and general appearance. These battery-powered devices usually include a battery component, a vaporizer or atomizer and a cartridge with a mouthpiece.
When the smoker puffs on the mouthpiece of the cartridge, the battery causes the tip of the e-cigarette to glow and the heat created by the battery turns the liquid nicotine into a vapor, or aerosol, of liquid, flavorings and nicotine. The aerosol can be breathed in and out by the user, creating a cloud that looks like cigarette smoke. Using an e-cigarette is commonly referred to as vaping.
The e-cigarette is sold as a metal tube that requires refillable containers of nicotine and flavorings, often called juice, and the cartridge generally contains up to 20mg of nicotine or more, but can also contain no nicotine. Some of the flavors available include coffee, tobacco, apple, strawberry, banana and bubble gum. The refill bottles contain up to 7 grams of nicotine.
There are also numerous inexpensive e-cigarettes available that are disposable and don’t require refilling the cartridge. These products can be discarded once the user depletes the liquid nicotine.
Safety, Quality, and Health Effects of E-Cigarettes
In July 2009, the Food and Drug Administration (FDA) Division of Pharmaceutical Analysis tested the ingredients in a small sample of cartridges from the two leading brands of e-cigarettes. They found that the samples contained detectable levels of known cancer-causing agents and other toxic chemicals, including diethylene glycol (commonly found in antifreeze) in one cartridge and nitrosamines in several cartridges.
The tests also found that there was no consistency in the levels of nicotine between different products with the same label. Some of the products labeled “no nicotine” still contained low levels of nicotine.
Like other forms of nicotine, the e-cigarettes and nicotine containers can be deadly to children or pets, who risk nicotine poisoning from ingesting the liquid nicotine. While most people may simply buy refill bottles from a tobacco retail store or vaping shop, some users refill their own cartridges at home. These refill bottles, as mentioned above, can contain up to 7 grams of nicotine. The fatal dose of nicotine for adults is estimated at 30-60 mg, while for children it is estimated at only 10 mg, or about 4 drops of a maximum strength refill bottle.
In 2014, the CDC studied the number of calls to poison centers involving e-cigarette liquids containing nicotine and found that they rose from one per month in September 2010 to 215 per month in February 2014. The number of calls per month involving conventional cigarettes did not show a similar increase during the same time period. More than half (51.1 percent) of the calls to poison centers due to e-cigarettes involved young children 5 years and under. In Nevada, between 2013-2015 a total of 97 calls were received related to nicotine-based e-cigarettes poisonings. Of the 97 calls, 63 (65%) were related to children under the age of 5.
Additionally, there is new cause for concern related to the secondhand e-cigarette aerosol (incorrectly called water vapor by the industry), because it has been found to contain nicotine, ultrafine particles and low levels of toxins that are known to cause cancer. People exposed to e-cigarette aerosol can absorb nicotine (measured as cotinine), with one study showing levels comparable to passive smokers. Exposure to fine and ultrafine particles may make respiratory ailments like asthma worse, and constrict arteries which could trigger a heart attack. FDA scientists have also found detectable levels of cancer-causing tobacco-specific nitrosamines in e-cigarette aerosol.
E-cigarettes contain and emit propylene glycol, a chemical that is used as a base in e-cigarette solution and is one of the primary components in the aerosol emitted by e-cigarettes. Short term exposure causes eye, throat, and airway irritation and long term exposure can result in children developing asthma. Even though propylene glycol is FDA approved for use in some products, the inhalation of vaporized nicotine in propylene glycol is not. Some studies show that heating propylene glycol changes its chemical composition, producing small amounts of propylene oxide, a known carcinogen.
Two recent scientific studies found that at least 10 chemicals identified in e-cigarette aerosol are classified as carcinogens and reproductive toxins. The compounds that have already been identified in mainstream (MS) or secondhand (SS) e-cigarette aerosol include: Acetaldehyde (MS), Benzene (SS), Cadmium (MS), Formaldehyde (MS,SS), Isoprene (SS), Lead (MS), Nickel (MS), Nicotine (MS, SS), N-Nitrosonornicotine (MS, SS), and Toluene (MS, SS).
In June 2014, the American Society for Heating, Refrigeration, and Air Conditioning Engineering (ASHRAE), the organization that develops engineering standards for, among other things, building ventilation systems published a study that concluded e-cigarettes emit harmful chemicals into the air and need to be regulated in the same manner as tobacco smoking. “There is evidence that nitrosamines, a group of carcinogens found specifically in tobacco, are carried over into the e-cigarette fluid from the nicotine extraction process… Consumers should be warned that, while the health risks associated with the usage of e-cigarettes are less than those associated with tobacco smoking, there remain substantial health risks associated with the use of e-cigarettes.”
Regulation of E-Cigarettes
In 2010, following a lawsuit by e-cigarette manufacturers, federal courts ruled that the FDA could regulate e-cigarettes as tobacco products under the Tobacco Control Act, but not as tobacco cessation aids.
In 2016, the FDA announced a rule establishing FDA oversight of e-cigarettes. Some of the key elements of the rule include:
- Review new tobacco products not yet on the market;
- Help prevent misleading claims by tobacco product manufacturers;
- Evaluate the ingredients of tobacco products and how they are made; and
- Registering manufacturing establishments and providing product listings to the FDA;
- Reporting ingredients, and harmful and potentially harmful constituents;
- Requiring premarket review and authorization of new tobacco products by the FDA;
- Placing health warnings on product packages and advertisements; and
- Not selling modified risk tobacco products (including those described as “light,” “low,” or “mild”) unless authorized by the FDA.
- In addition, there are several provisions aimed at restricting youth access to tobacco products, including:
- Not allowing products to be sold to persons under the age of 18 years (both in-person and online);
- Requiring age verification by photo ID;
- Not allowing the selling of tobacco products in vending machines (unless in an adult-only facility); and
- Not allowing the distribution of free samples.
- Communicate the potential risks of tobacco products.
At the state and local level, many governments have chosen to limit and regulate e-cigarettes. Many entities have banned the use of e-cigarettes in areas where smoking is already prohibited, by adding vaping to existing smoke-free laws. Others are banning or limiting the sale of e-cigarettes to minors. Another approach is to regulate who can sell e-cigarettes, by requiring tobacco retailer licensure in order to sell.
Just a few years ago, there were only a handful of U.S. companies that sold e-cigarettes, though most e-cigarettes were still made in China. Now, however, many companies make and sell e-cigarettes, including US tobacco companies Altria, Reynolds and Lorillard.
There has been a rapid expansion of marketing e-cigarettes, in print, radio, television, and billboard advertising nationwide. E-cigarettes are also heavily sold online. Many times, the e-cigarette is marketed as a way to get nicotine in places where smoking is not allowed or as a recreational alternative to smoking. Several e-cigarette marketers are also marketing their products as a means to quit smoking, despite a lack of credible evidence that says they are effective.
Attitudes and Usages
Sales of e-cigarettes have grown rapidly in the United States, and after doubling every year since 2008, sales in 2013 are now accelerating even faster and projected to reach $1.7 billion. The cost of e-cigarettes has fallen dramatically, as well, making them more affordable, and thus more attractive to young people.
- Recent findings from the National Youth Tobacco Survey, conducted by the Centers for Disease Control and Prevention, show that there was a 10-fold increase in current e-cigarette use among high school students between 2011 and 2015 – from 1.5 percent to 16 percent. E-cigarettes are now by far the most commonly used tobacco product among youth. In 2015, a record-high 3 million middle and high school students used e-cigarettes – compared to 1.6 million who smoked cigarettes.
Research indicates that aggressive marketing to youth may have played a role in the dramatic increase.
2015 Nevada Youth Risk Behavior Survey results show that 24.8% of Clark County high school students reporting current use of e-cigarettes.
While more studies are likely to be conducted on the safety, efficacy, and integrity of e-cigarettes in the months and years to come, most public health professionals agree it is premature to call e-cigarettes a safe alternative to traditional cigarettes. Additionally, the dramatic increase of e-cigarette usage by youth and the ever present marketing of e-cigarettes to all populations have created concern with public health leaders.
“These data show a dramatic rise in usage of e-cigarettes by youth, and this is cause for great concern as we don’t yet understand the long-term effects of these novel tobacco products,” said Mitch Zeller, director of FDA’s Center for Tobacco Products. “These findings reinforce why the FDA intends to expand its authority over all tobacco products and establish a comprehensive and appropriate regulatory framework to reduce disease and death from tobacco use.”
- ASHRAE Journal. “The Hazards of E-Cigarettes,” June 2014.
- American Cancer Society, Prevention and Early Detection. “Guide to Quitting Smoking,” Revised May 2009.
- American Legacy Foundation. “Tobacco Fact Sheet: Electronic Cigarettes,” Revised June 2013.
- Americans for Nonsmokers’ Rights. “Electronic Cigarettes and Secondhand Aerosol,” 2014.
- Public Health Law and Policy, Technical Assistance Legal Center. “Electronic Cigarettes: How They Are- and Could Be- Regulated,” July 2011.
- Campaign for Tobacco Free Kids. “FDA and the States Must Regulate E-Cigarettes to Protect Public Health: Our Policy Regarding E-Cigarettes,” July 2013.
- Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. “Electronic Cigarette Use Among Middle and High School Students — United States, 2011–2012,” Volume 62, Number 35, September 6, 2013.
- Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report. “Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014,” Volume 63, Number 13, April 4, 2014.
- "Nevada Youth Risk Behavior Survey." Division of Health Sciences. 2015. Web. 06 May 2016."U.S. Food and Drug Administration." Extending Authorities to All Tobacco Products, Including E-Cigarettes, Cigars, and Hookah. Web. 06 May 2016.