E-Cigarettes: Clearing the Air

APRIL 08, 2016
Anyssa Garza, PharmD
Myth 4: The Flavorings in e- Cigarettes Are Safe
By January 2016, e-cigarettes were available in 7764 flavors, including Chocolate Treat, Snappin’ Apple, and Vanilla Dreams. The main focus of concern has been nicotine, but what about the potential toxic effects of the inhaled flavorings?1

In a Journal of the American Medical Association article, Barrington-Trimis et al stated, “Recent in vitro studies found that the cytotoxic effects of e-liquids were largely restricted to flavoring components.”1 In addition, these researchers suggest that the potential toxic effects from inhaled flavorings are largely unrecognized.1

Myth 5: e-Cigarettes Do Not Produce Harmful Secondhand Smoke
In general, e-cigarettes contain nicotine and other harmful substances that are inhaled by users. Unfortunately, little is known about how the vapors affect bystanders.7 Recent study results showed e-cigarettes may involuntarily expose bystanders to nicotine. Further research is warranted to test exposure to the toxic constituents of the vapors emitted from e-cigarettes and their effects on health.8

Conclusion
The ALA has voiced concerns about e-cigarettes being a “gateway” to conventional cigarettes5 and has referred to a recent study that evaluated middle school and high school students. The study revealed “an alarming increase in the number of middle and high school students who used e-cigarettes but never smoked a cigarette.” The study also found that these youths were almost 2 times more likely to intend to begin smoking regular cigarettes compared with youths who had never used e-cigarettes.9

The alarming increase is likely a result of a combination of factors, such as the following:
  • Age verification is not required to purchase e-cigarettes online; they are readily accessible to everyone, especially youths. In 2015, a group of researchers measured the rate at which minors could successfully purchase e-cigarettes online in North Carolina: despite North Carolina’s 2013 e-cigarette age-verification law, the buy rate was 93.7% and none of the vendors were compliant with the e-cigarette age-verification law.10
  • E-cigarettes come in many flavors, as previously mentioned; have attractive packaging; and are available to purchase online.6 In addition, there are nearly 500 brands. Therefore, the noticeable increase in the number of youths using e-cigarettes should not be a surprise.
  • E-cigarettes have been promoted as appealing by movies, television, celebrities, and social media, and youths can be highly influenced by popular media.
  • E-cigarettes may be appealing to many because they simulate the experience of smoking a cigarette and deliver nicotine to the lungs (Online Table2). 
Table: The Appeal of e-Cigarettes
●       Address the psychopharmacologic, social, and behavioral aspects of smoking
●       Simulate the experience of smoking a cigarette:
â—‹       The vapor simulates tobacco smoke
â—‹       Handling the device simulates the hand-to-mouth experience of cigarette use
â—‹       The flavors simulate or enhance the taste of cigarettes
●       Deliver nicotine to the lungs to relieve nicotine withdrawal symptoms
●       Are perceived to help quit or reduce smoking
●       Are perceived to be a healthier and safer alternative to conventional cigarettes
●       Bypass smoking restrictions
●       Decrease costs associated with tobacco dependence
Adapted from reference 2.

An online search for e-cigarettes presents endless information from e-cigarette manufacturers. Most of this information is biased and inaccurate. Health care professionals should be aware of the kind of misinformation their patients may be seeing and be prepared to counsel patients on the efficacy of e-cigarettes as a smoking cessation treatment and on the associated risks.


Dr. Anyssa Garza received her doctor of pharmacy degree from the University of Texas at Austin. She is currently working as the director of the Life Sciences Library at RxWiki, where she continues to build her practice on the fundamental belief that providing patients with medication information and medical knowledge contributes significantly to the quality of care they receive and improves quality of life and health outcomes. Her work focuses on educating patients and providing them with the resources needed to navigate the overwhelming and complex health system. Before RxWiki, she was director of pharmacy for a Central Texas Department of Aging and Disability facility.

References
  1. Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in electronic cigarettes: an unrecognized respiratory health hazard? JAMA. 2014;312(23):2493-2494. doi: 10.1001/jama.2014.14830.
  2. Ebbert JO, Agunwamba AA, Rutten LJ. Counseling patients on the use of electronic cigarettes. Mayo Clin Proc. 2015;90(1):128-134. doi: 10.1016/j.mayocp.2014.11.004.
  3. Drug facts: electronic cigarettes (e-cigarettes). National Institute on Drug Abuse website. drugabuse.gov/sites/default/files/drugfacts_e-cigs_9_15.pdf. Published August 2015. Updated August 2015. Accessed October 18, 2015.
  4. American Lung Association statement on e-cigarettes. ALA website. lung.org/our-initiatives/tobacco/oversight-and-regulation/statement-on-e-cigarettes.html. Updated March 2015. Accessed September 17, 2015.
  5. Summary of results: laboratory analysis of electronic cigarettes conducted by FDA. FDA website. www.fda.gov/NewsEvents/PublicHealthFocus/ucm173146.htm. Updated April 22, 2014. Accessed October 20, 2015.
  6. FDA and public health experts warn about electronic cigarettes [news release]. Silver Spring, MD: FDA; July 22, 2009. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm173222.htm. Accessed October 18, 2015.
  7. Myths and facts about E-cigarette. American Lung Association website. lung.org/stop-smoking/smoking-facts/myths-and-facts-about-e-cigs.html. Accessed September 17, 2015.
  8. Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine Tob Res. 2014;16(6):655-662. doi: 10.1093/ntr/ntt203.
  9. E-cigarette use among non-cigarette smoking youth triples [press release]. Washington, DC: American Lung Association; August 25, 2014. lung.org/about-us/media/press-releases/e-cigarette-use-triples-in-nonsmokinr-youth.html. Accessed September 17, 2015.
  10. Williams RS, Derrick J, Ribisl KM. Electronic cigarette sales to minors via the Internet. JAMA Pediatric. 2015;169(3):e1563. doi:10.1001/jamapediatrics.2015.63.


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