E-cigarettes and Vaping: Risk Reduction and Risk Prevention

William V. Hyman, PhD1; Stephen L. Brown, PhD2

1
Professor, Population Health, Sam Houston State University, Huntsville, TX
2
Associate Professor, Population Health, Sam Houston State University, Huntsville, TX
[email protected]
ABSTRACT cigarettes (e-cigarettes).7 Smoking and smokeless tobacco use
The decline in smoking over that last half century has been a patterns are typically established during the adolescent years.6
significant public health achievement in the U.S. The emer- Nearly 9 out of 10 adult cigarette smokers began smoking be-
gence of e-cigarettes may hold potential for aiding smoking fore the age of 18,1,8 and smokeless tobacco use also almost
cessation efforts, but may also create new opportunities for always begins by the time youth graduate from high school.
nicotine experimentation. This paper reviews the emerging e- The peak years for first initiation appear to be grades six and
cigarette industry, its marketing approaches, and recent steps seven (or between the ages of 11 and 13), with some starting
to regulate labeling, distribution and advertising. It summa- even earlier.9 Further, among those who currently use tobacco,
rizes current research on the efficacy of e-cigarettes as smok- one-half of males and almost one-third of females report us-
ing cessation aids as well as their potential health effects. It ing more than one tobacco product in the past 30 days.6 This
also discusses how young people might be particularly vulner- early tobacco use often becomes a strong addiction that can
able to the allure of these new products. Finally, it outlines overwhelm attempts at cessation. Clearly, any strategies to
steps prevention specialists and health educators, especially decrease future tobacco use must be three-pronged: helping
those working with young people, could take to respond to current users quit, preventing occasional users from becom-
this new trend. ing addicted regular users and preventing youth from experi-
menting with tobacco-related products.9 If the decline in ciga-
Key words: e-cigarettes, vaping, risk prevention, adolescents rette use among teens is to continue, full implementation of
BACKGROUND comprehensive tobacco control programs must be combined
The recent decline in smoking over the last half century is with reductions in advertising and commercial availability of
considered an important public health success.1 The propor- tobacco-related products.2, 10
tion of adults who report smoking in the U.S. has decreased Emergence of E-cigarettes
from 42.4% in 1965 to 17.8% in 2013, and the percentage of While use of most forms of tobacco has been decreasing, the
high school students reporting smoking has declined from a increase in use of e-cigarettes is a recent phenomenon with
high of 36.0% in 1997 to 9.2% in 2014.2 While these smok- some positive benefits, but also some potential concerns for
ing declines have significantly improved the health profile of both public health and clinical medicine.11 Electronic ciga-
Americans, they still fall short of the Healthy People 2020 rettes are the most common type of electronic nicotine deliv-
goal of 16.3 In 2011, the percent of Texans who currently ery systems (ENDS).12 These products deliver nicotine in the
smoke was 19.2 and the percent of youth in grades 9-12 was form of a vapor inhaled by the user (known as the vaper).
17.4, higher than national averages.4 With about one-sixth of They contain an atomizer that converts the contents of a nico-
the population currently smoking, clearly there is still room tine cartridge into a vapor when heated and a battery-operated
for improvement.1 Tobacco use remains the single most pre- heating element to produce the heat for the atomizer. The
ventable cause of disease, disability, and death in the United heating and vaporization may be initiated by pressing a but-
States, with an estimated 443,000 people dying prematurely ton or by inhalation by the user. E-liquids may be similar in
each year from smoking or exposure to secondhand smoke, taste to tobacco or may contain other flavoring (mint, coffee,
and another 8.6 million living with a serious illness caused chocolate, etc.) and are sold as replaceable cartridges, refill
by smoking. Though not posing as great a risk, smokeless to- liquids, or as one-use disposable e-cigarettes. Unlike con-
bacco products also increase risk for death or disease, beyond ventional tobacco cigarettes, the vaporization does not cause
the above mentioned totals. In addition to these mortality and combustion and tobacco smoke. As with any novel product,
morbidly risks, users also bear the physical, psychological, different brands of e-cigarettes with various versions of the
and financial burden of nicotine addiction, with millions of devices are available. They are often fashioned to look like
Americans continuing to use tobacco-related products despite cigarettes, pipes, and cigars, but may also have the appear-
the health risks.5 ance of common items (e.g., pens, memory sticks) so as not to
LITERATURE REVIEW bring attention to their use in some cases or in other cases as
Early Tobacco Experimentation a matter of novelty or personal.12-14 After being developed in
Every day in the U.S., more than 3200 teens under the age China in 2003, e-cigarettes entered the U.S. market in 2007.12,
of 18 smoke their first cigarettes, and each day, approximate-
13
Awareness of and interest in e-cigarettes increased rapidly
ly 2100 youth and young adults who have been occasional among potential consumers.15-17 In 2013, 50 percent of U.S.
smokers become daily cigarette smokers.6 In 2012, 6.7% of smokers had tried e-cigarettes, up from 32 percent just one year
middle school and 23.3% of high school students reported earlier.12 While the overall use patterns of e-cigarettes are un-
current use of tobacco products. These products included not clear, use appears to be highest among current smokers, those
only cigarettes, but also cigars, snus, smokeless tobacco, hoo- with higher education and income, non-Hispanic whites, as
kahs, pipes, bidis, kreteks, dissolvable tobacco, and electronic well as among young adults.16,18 Increased use of e-cigarettes
TPHA Journal Volume 69, Issue 1 13
is partly the result of increased advertising for the products.19 to the Office of Management and Budget to extend its author-
Though television and radio have not been important venues ity to regulate additional nicotine-containing products. Effec-
for tobacco advertising since the 1970s, these products have tive August 2016, the new regulation bans e-cigarette sales to
been aggressively marketed through other channels, includ- minors under age 18 and will require stronger warning labels
ing online marketing. Advertising of e-cigarettes accelerated starting in 2018.32, 33 The rule does not ban internet marketing,
with the acquisition of e-cigarette brands by and competition where a significant portion of sales are thought to occur,34 but
among major tobacco companies.20, 21 Sales from e-cigarettes does require reliable age verification for online sales. Perhaps
rose rapidly from $250 million in 2011 to nearly $1 billion the most controversial part of the new rules is a requirement
by 2014.22, 23 However, there seems to be some disagreement for pre-market review of any new devices, which requires e-
as to the size of the industry because it is difficult to capture cigarette makers to assure that they are safe. Some contend
the magnitude of online sales. Nielson estimated that 2015 that such pre-market reviews will be prohibitively expensive
brick-and-mortar sales were $850 million (though this may be and may prevent forth-coming product improvements.
hard to estimate with small vape shops opening and closing
frequently). Wells Fargo estimates, that if online sales are in- Many states, including Texas, were ahead of the federal gov-
cluded, the total market was over $2.5 billion in 2015.24 Late ernment in regulating the sale of e-cigarettes. Texas, Senate
2015 and early 2016 data showed declines in convenience Bill 97 became law in Late 2015. The most prominent parts of
store sales and reports that major tobacco companies may be the law prohibit sale of e-cigarettes to minors and require age
losing interest in this segment of the market.25 verification for online sales to Texas residents. The state law
goes beyond FDA rules by making the use of these products
Youth and Vaping by minor a Class C misdemeanor resulting in a fine and man-
Data from the most recent National Youth Tobacco Survey datory tobacco education. Further, it prohibits second-hand
show that current e-cigarette experimentation (i.e., have you exposure to vapor in public buildings, including, schools, el-
ever tried an electronic or e-cigarette) among middle and evators, theaters, libraries, and public transportation.35
high school students tripled from 2013 to 2014, increasing
from 4.5 to 13.4 percent, which translates in to 1.3 million Because there has been no previous federal oversight of e-cig-
more high school and 300,000 thousand more middle school arettes, which would require the FDA to fully evaluate them
students trying them. The authors noted that this is the first for safety, there are many unanswered questions about the
time in survey history that current e-cigarette use has sur- safety and efficacy of these products.14,22 For example, lim-
passed current use of every other tobacco product overall, ited studies by the FDA have revealed issues with substandard
including conventional cigarettes.26, 27 The 2014 Texas Youth or non-existent quality control over these products. Findings
Tobacco Survey reported that nearly one-fourth of all middle included mislabeling of the nicotine content (some labeled as
and high school students reported lifetime e-cigarette use, and containing no nicotine were found to have nicotine and varied
14% reporting using e-cigarettes in the last 30 days. Whats inhaled nicotine content were found in products bearing the
more, nearly one-fourth of current e-cigarette users had never same label.14 The FDA has previously warned some e-cig-
smoked conventional cigarettes.28 What we cant tell from arette manufacturers for making unsubstantiated claims and
these data is whether this is one-time experimentation or the for poor manufacturing processes as a violation of the Federal
beginning of regular use. Due to several factors, including Food, Drug, and Cosmetic Act (FDCA).14
ease of operation set up, low financial investment, and mini-
mal advertising requirements, sources estimate that more than Safety
half of all e-cigarettes are sold on the internet. With no cur- A systematic review of early chemical, toxicological, and
rent direct regulation, internet marketing offers an easy path- clinical studies showed that chemical exposures from e-
way of selling to youth. According to a recent Morbidity and cigarettes are much lower than those resulting from tobacco
Mortality Weekly Report (MMWR), about seven out of every smoke and are lower than those allowed by the FDA in other
ten middle and high school students reported some exposure situations.36 Because there is no tobacco combustion in an e-
to e-cigarette advertisements in 2014. The authors expressed cigarette, some manufacturers and distributors have claimed
concern about whether viewing these advertisements might that their products are a safer alternative to conventional
lead to increased use of e-cigarettes among teens (Singh et al., cigarettes. However, these claims have been rejected by the
2016).29 As discussed below, the adverse effects of nicotine FDA.37 Because these products have been unregulated, the
may be particularly pronounced in adolescents. There is con- nicotine levels and other contents of e-cigarettes vary greatly
cern that e-cigarettes may increase nicotine addiction among and, as mentioned earlier, are not always consistent with the
youth and that they might lead youth to try other tobacco- label.38, 39 Further, some e-cigarettes are reported to contain
related products.14,30 varying amounts of other compounds that are potentially
harmful to humans, including nitrosamines and diethylene
Regulation glycol, though not likely to the same degree as smoked to-
While the United States Food and Drug Administration bacco.40 It has also been shown that cells exposed to the vapor
(FDA) has regulated cigarettes, cigarette tobacco, smokeless from e-cigarettes show unhealthy changes similar to, though
tobacco, and roll-your-own tobacco products for years, until not as dramatic as, cells exposed to tobacco smoke.41 The au-
recently, e-cigarettes have not been regulated as a specific to- thors of the aforementioned systematic review conclude their
bacco product.31 In early 2016, the FDA submitted a request
14 TPHA Journal Volume 69, Issue 1
recommendations by cautioning that the results as reviewed extended use, in turn, increases the risk of long-term, health
are only preliminary and there are no studies on the long-term consequences.6 Unfortunately, many of these addicted youth
effects of inhaling heated, propylene glycol, glycerol or vari- report wanting to quit but being unable to do so.
ous added flavorings.36
Cessation
These potential ill-effects of e-cigarettes have led to warnings Like the evidence on the long-term effects of e-cigarettes, in-
by the FDA about the risks of unregulated sales on the Internet formation on the impact of e-cigarettes on smoking cessation
and a Surgeon General report stressing the need for quanti- is also inconclusive. Based on current available research, e-
fying the level of risk for long-term use of non-combusted cigarettes cannot be promoted, at this time, as providing any
sources of nicotine, especially if long-term use of these nico- benefit in smoking cessation.46
tine sources becomes more common.42 As discussed above,
increased use of these products is clearly occurring. Nicotine is an addictive psychoactive drug.1 Pharmaceutical
medications and nicotine replacement therapy (NRT) have
Though not common, there are other potential safety issues been shown to increase smoking quit rates.47 However, even
secondary to intended used. FEMA reported at least two with the use of NRT, the percentage of smokers who return
dozen verifiable incidents of e-cigarette devices exploding or to smoking within six months is reported through meta-anal-
catching fire, at least nine resulting in injury.43 And the CDC ysis to be 93%.48 As an electronic nicotine delivery system
has noted an increase in poisoning related to mishandling of (ENDS), e-cigarettes provide varying amounts of nicotine.
refillable liquids, most in children under the age of five.44 The efficacy of e-cigarettes as an alternative nicotine deliv-
ery system has been posited and claims have been made that
Nicotine e-cigarettes may be helpful for smoking cessation.49 If true,
Although the FDA has recently concluded that nicotine re- these products may play an integral role in the ongoing fight
placement products do not pose high risk for abuse or depen- against smoking.
dence,45 nicotine is addictive and may hold some potential
health risks, though not as many as smoked tobacco products. However, evidence of e-cigarettes as a smoking cessation aid
In The Health Consequences of Smoking50 Years of Prog- through controlled trials and large cross-sectional studies is
ress: A Report of the Surgeon General, the summary of find- currently scant.50 A few reports supporting effectiveness show
ings shows a likely link between nicotine and an increase in increased abstinence using e-cigarettes compared to tradi-
heart rate, an increase in myocardial contractility, an increase tional methods or cold turkey60.51 Some studies report ces-
in coronary vascular resistance, and a decrease in insulin sen- sation rates from 22.5 to 70 percent with additional smokers
sitivity, all contributing to increasing cardiovascular risk in reducing their cigarette consumption by as much as 50%.11,52
nicotine users.1 Other studies have supported the effectiveness of e-cigarettes
in reducing the craving for cigarettes, even suggesting that the
It is not clear if nicotine is a carcinogen in humans, but it is mere presence of the smoking stimuli without the presence of
known to affect deregulation of biological processes including nicotine may reduce cravings.53, 54
angiogenesis, which might promote the growth of existing tu-
mors.22 Being bioactive for a number of carcinogenic mecha- Conversely, other studies show that e-cigarette users are less
nisms in experimental systems, nicotine might be associated likely to be totally abstinent from cigarettes than those who
with increased rates of oral, esophageal, or pancreatic can- have never used e-cigarettes and that, despite reducing total
cer. Nicotine has also been linked to other possible ill-health cigarette consumption, e-cigarette users were no more likely
impacts including affecting cellular immunity and mediating than cigarette smokers to have quit smoking permanently.55,
adverse effects of smoking on reproductive health (including 56
Further, Bullen et al. report that e-cigarette users achieved
preterm delivery, stillbirth, and other adverse health outcomes similar abstinence as those using nicotine patches, but that
for the developing fetus).3 dual use (simultaneously using NRT and tobacco products)
persisted longer with e-cigarette users than patch users.57 A
The adverse effects of nicotine may be particularly pro- systematic review of 38 studies published in Lancet Respi-
nounced in adolescents. Based on animal studies, knowledge ratory Medicine found no benefit for using e-cigarettes as a
of adolescent brain development, and limited studies from smoking cessation aid (though some researchers are debating
young smokers, it is possible that nicotine exposure during the rigor of the studies included).46 Thus, some in the medical
adolescence adversely affects cognitive function and develop- community are suspicious of the therapeutic claims of e-cig-
ment. Therefore, the potential long-term, cognitive effects of arettes, and some medical organizations currently discourage
exposure to nicotine in youth are of great concern.1 There is practitioners from counseling their clients to use e-cigarettes
also a body of evidence that suggests the higher sensitivity as a primary cessation avenue until further supportive evi-
to nicotine among adolescents can create dependence sooner dence is available.50,58 Though its too soon to tell, there is
than for adults. Specifically, those with earlier initiation of some encouraging news from the National Health Interview
smoking are more likely to develop greater nicotine addiction Survey showing that while 12.6% of Americans tried an e-
than those who start at a later age.6 The majority of those cigarette in 2014, only 3.4% of non-smokers have tried one
who smoke during adolescence are addicted by age 20. This and only 0.4% of people who never smoked a combustible
addictive behavior is likely to continue into adulthood. This cigarette currently used an e-cigarette, hopefully suggesting
TPHA Journal Volume 69, Issue 1 15
that current adult non-smokers dont seem to be attracted to others, future research must focus not only on the long-term
the product.59 health effects of ENDS, but also on the long-term use patterns
and how users transition from use of one nicotine product to
An interesting framework for quantifying the total public another and to no use.60 Its will be important to understand the
health impact of e-cigarettes was recently proposed by Levy answers to these long term questions. Do adolescent ENDS
et al.60 Taking an epidemiologic approach, they suggest a experimenters continue to be life-long users? Do current
sequence of questions that must be answered before we can smokers who use ENDS eventually give up smoking? Do cur-
determine whether this product should we viewed primarily rent smokers eventually give up nicotine? Do former smok-
through a harm reduction or risk prevention lens. Firstly, we ers come back to their nicotine habits because they perceive
must ask about the proportion of users: current smokers, for- ENDS as less harmful?
mer smokers or those who have never smoked. Then, we must
try to determine what would have happened in the absence of Just as it has been expanded to include smokeless tobacco
the e-cigarette option. For example: Would non-smokers have (and other forms of tobacco administration), tobacco educa-
been attracted to some nicotine product anyway? Would cur- tion must now include content on e-cigarettes. Youth must
rent smokers have given up smoking anyway? Thirdly, we understand that there are no harmless, nicotine-related prod-
must ask how long each behavior would have continued: how ucts, and this includes e-cigarettes. Despite the fact that they
long they would have abstained, how long they would have are non-combusting and produce no smoke, the emissions
used the e-cigarette product and how long they would have and nicotine content of these products is not without risk. Al-
smoked. Finally, we must determine the final status of us- though the emissions from e-cigarettes likely contain fewer
ers: no nicotine, only e-cigarettes, only smoking, or dual use. toxic compounds than the smoke from cigarettes, it is too ear-
As can be observed from this list of questions, these products ly to conclusively determine the long-term effect of inhaling
could lead to a total increase or decrease in harm, depend- these heated vapors. Plus, the nicotine delivered has potential
ing on the proportions in each category. However, until we health risks that must not be overlooked. We should not be
have longitudinal data to accurately answer these questions, it deceived. Early onset of the use of any nicotine containing
seems prudent to take very cautious approach. product is likely to lead to increased nicotine dependence
among users. In school health education, youth should be
Implications for Risk Prevention taught that the nicotine in these products is an addictive drug
The health promotion community must understand these and should be classified with the other addictive substances in
trends in e-cigarette use and health professionals who work the drugs unit of the curriculum. Youth should also be taught
with youth must respond to changing tobacco and tobacco- that inhaling anything, except clean air, into their lungs pres-
like product trends. Clearly, health professionals should not ents potential short- and long-term risks. Safer than ciga-
rely solely on e-cigarette industry claims regarding the health rettes does not mean safe.
benefits of their products. While this approach, aimed at risk
reduction, is commendable and not without merit when prop- As revenue from conventional tobacco products continues
erly implemented, health promotion professionals, especially to decline in the U.S., health professionals should expect the
those who work with impressionable youth, must keep risk influence of the powerful tobacco industry in the e-cigarette
prevention emphasized in the mission of tobacco education market. In the process, they should also expect the emerg-
efforts. ing e-cigarette industry to seek creative marketing strategies
for adults that will also appeal to youth (despite regulations
Should conclusive evidence be presented and these products against specifically targeting youth), just as the tobacco indus-
be approved as a smoking cessation tool, then that avenue of try has done with other tobacco products in the past.
cessation should be offered just as any other cessation method
is currently with accurate pros and cons, statistics that rep- Educators should understand that youth are enamored by nov-
resent true and total cessation figures as compared to other el products. The fun delivery devices and variety of flavors
cessation methods, and prescriptions or other controls on the might hold special appeal to youth to try these new products,
sale of these cessations products. And if shown to be effective particularly when they may have heard they are harmless and
in harm reduction for some smokers, that information should when they are being advertised as trendy and sophisticated.
also be presented in tobacco education. However, reducing Young people are uniquely vulnerable to the powerful influ-
the number of cigarettes smoked or replacing one form of nic- ence of advertising, and perhaps more so than adults to the ex-
otine addiction for another, though improving overall health, posure of internet advertising, where much of the e-cigarette
should not the ultimate goal of health promotion. Though marking is expanding.
smoking fewer cigarettes or inhaling fewer toxins is a step
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18 TPHA Journal Volume 69, Issue 1
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