Are E-Cigarettes a Wolf in Sheep’s Clothing?

Since January 1, 2014, more than one study a week has been published that examines the ubiquitous e cigarette for health effects—quite often for harmful effects. A great many studies report that e cigarettes have some negative health effects, albeit far less severe than from smoking tobacco. One health effect that should not be in debate is the effect of nicotine on addiction recovery. Hilton and White (2013) pointed out that nicotine, contrary to the “recovery crutch” hypothesis, poses a significant threat to self-sustainable addiction recovery. That paper encouraged counselors and other addiction professionals to include nicotine addiction coincident with the treatment of alcohol and drug addiction. One new tool that might help some recovering addicts eliminate nicotine use might be e cigarettes.

E cigarettes have become a very popular alternative to tobacco as nicotine delivery systems. The exploding market for e cigarettes and other tobacco-free nicotine delivery systems underscores that nicotine is an addictive drug, and that smoking is just one way to consume the drug. E cigarettes do offer a more socially acceptable way to dose than cigarettes. People can and do suck on them—referred to as “vaping”—in many public places despite smoking bans revised to include e cigarettes in most major cities. Second, they are not a fire hazard, as they do not need to be ignited with fire to use. Third, they do not produce dangerous second-hand tobacco smoke to family members and others. Fourth, e cigarettes offer a tool for eventual withdrawal, as vapers can adjust the dosage of nicotine inhaled. But, are they safe? Are they effective?

One thing to keep in mind is that nicotine, no matter how it is delivered to the body, is a toxin. Although it might be argued that nicotine alone is harmless, such an assertion is factually wrong.  Professor Edward Domino (1999), a pharmacologist at the University of Michigan, pointed out that a century ago nicotine was used as an insecticide. If it kills bugs (think DDT), what is it doing to people? Attesting to nicotine’s neurotoxicity, Domino pointed out that American Indians often smoked concentrated tobacco to achieve hallucinations for spiritual rituals. His summary of the pharmacological effects of nicotine mentions enhanced alertness, improved memory, and relaxation under stress. It also lists addiction, withdrawal, tremor, convulsions, and death, depending upon dose and duration of use.  

Are e cigarettes safe? Safety is a reasonable concern. Nobody wants a cure that is worse than the disease. Unfortunately, both medical science and the media have stoked confusion regarding e cigarette safety. Reports on the hazards of e cigarettes are appearing almost daily in the popular press, often with alarmist headlines such as “Study Finds Teens Flocking to E Cigarettes,” which appeared in The Washington Times (Wetzstein, 2014). Most of these headline-grabbing studies represent junk science. Either they are not done in the context of relative harm reduction for smokers or they sensationalize trivial or poorly-reasoned results. The research community also has contributed the confusion. For example, anti-tobacco crusader and past editor of the journal Tobacco Control, Dr. Sidney Chapman, published an editorial in the European Journal of Public Health (2014) expressing skepticism that e cigarettes will be found to be safe despite presenting no evidence to support his assertion. In an open letter to World Health Organization (WHO) Director General Margaret Chan, forty-seven international researchers asserted that confusion regarding e cigarette safety has been, in part, due to poorly-designed studies and an evident “anti-tobacco bias” in some interpretations (Abrams et al., 2014).  

Attempts have been made to systematically weed out junk science in an effort to examine e-cigarette safety.  Callahan-Lyon (2014) conducted a meta-analysis of forty-four studies and concluded that e cigarette safety could not be determined due mainly to weaknesses in many of the study research designs. A second meta-analysis sponsored in part by the WHO (Grana, Benowitz, & Glantz, 2014) concluded that compared to tobacco cigarettes, e cigarettes were often less toxic by an order of magnitude (i.e., ten times less). Most recently, a third meta-analysis by the prestigious Cochrane Collaborative (McRobbie, Bullen, Hartman-Boyce, & Hajek, 2014) looked at twenty-nine studies. They found no significant safety issues related to e cigarette use.

In March of 2015, addiction researcher Michael Siegel at Boston University published an op-ed article in The Wall Street Journal trying to offset the ubiquitous anti-e-cigarette hysteria in the popular press regarding their threat to public health. Siegel rightly called e cigarette health warnings issued by medical authorities—such as the director of the Center for Disease Control—as unwarranted and unsupported by research. He also sharply criticized the California Department of Public Health for publishing misleading pamphlets about e cigarette safety and effectiveness, then mounting a campaign to ban the devices statewide regardless of data showing them to be far safer than tobacco cigarettes—which the Department has made no effort to ban (O’Connor, 2014). In summary, compared to tobacco cigarettes, e-cigarettes have been shown to be safer and less toxic. 

But, are e cigarettes effective for use as quitting aids? The Cochrane Collaborative study (McRobbie et al., 2014) reported that e cigarettes reduced tobacco smoking by 50 percent, that they were equal to or better than commonly used nicotine replacement therapy (NRT) like the nicotine patch, and were far superior to willpower alone. Other data also suggest that the vast majority of e cigarette users do reduce their use of tobacco, and some e cigarette users have stopped smoking altogether. Several recent studies present self-report data from e cigarette users that they cut down on tobacco smoking, and some said that they reduced the amount of nicotine being delivered by their e cigarettes since first trying them (see Adkinson et al., 2013; Bullen et al., 2013; Caponnetto et al., 2013).  

One of the most conclusive studies to date is a randomly controlled trial of over 5,800 smokers attempting to quit in England (Brown et al., 2014). The study compared reports of abstinence among people using over-the-counter NRT patches, e cigarette users, and those relying upon willpower alone (cold turkey). Results for quitting showed that both NRT and e cigarettes were superior to willpower alone. However, abstinence claims were not biologically verified—a disappointing weakness for a clinical trial. However, analyses conducted in the Brown et al. (2014) study support an earlier assertion by Bullen et al. (2013) that e cigarettes assist withdrawal in a fashion similar to that for NRT. A noteworthy observation by Brown et al. is that e cigarette users achieved abstinence without any formal instruction on how to use the product for that purpose.  

The answer to the question begged in my “sheep’s clothing” title is that it depends. Many things in life can be used for good or ill purposes, and e cigarettes are no exception.  

The addictive properties of nicotine have for centuries ensured a market for tobacco products. I have personally seen smoking persist even while users cough up blood and tissue from lung deterioration. The nicotine in e cigarettes likewise ensures a market for nontobacco nicotine delivery systems. In time, e cigarettes may be engineered to deliver more potent doses of nicotine than tobacco cigarettes. That would be unfortunate. Currently, e cigarette producers leave dose potency to the customer, but research shows wide variability among products in dose delivered (see Goniewicz et al., 2013). Thus, it is feasible that some people may increase their dosages with the hope of increasing the effect of the drug, thereby increasing their addiction and dependence on these devices. E cigarettes are already showing signs of being more profitable than tobacco products. Currently, e cigarettes rarely suffer from high tobacco taxes, and nicotine cartridges are cheaper to produce and deliver to consumers than cigarettes. In addition, the lack of negative social stigma associated with product use (Wieczner, 2013) should increase their appeal to many tobacco smokers. Is it any wonder that e cigarette marketing is becoming more aggressive?  

Aggressive advertising with unsubstantiated claims surely exemplifies a wolf-in-sheep’s-clothing image. For example, in a 2013 review by Lynn in PC Magazine of all places, the author emphasized “Fairly authentic smoking experience. Odorless. Variety of flavors. Futuristic design. Re-chargeable battery.” What do e cigarettes have to do with computers? The article was clearly a promotion masquerading as a computer product review. The article went on to touch on the point that the manufacturer adds pleasing flavors to the vapor. Flavoring is a lesson learned from menthol cigarettes. Research has shown that flavor enhancement is associated with product preference and increased smoking (see Giovino et al., 2004; Moolchan, 2004). 

A looming concern among public health officials is that e cigarettes might be, as Jan Wieczner (2013) at The Wall Street Journal put it, “Big tobacco in disguise.” It may be that the industry has found a way to legally sustain nicotine addiction, thereby ensuring market growth. There are also many articles predicting widespread exclusive use by teens, in part because of the flavoring. Of course, nobody has questioned whether flavoring makes e cigarettes a more appealing option to tobacco smoking, and thus less harmful.

E cigarettes appear to be evolving into a popular tool for kicking the smoking habit. Pulvers et al. (in press) report results from a national survey in which 40 percent of vapers report using the devices to reduce their tobacco smoking. I have already mentioned research showing that vaping does indeed increase reduced tobacco use and is effective in achieving abstinence.

Of course, e cigarettes are toxic and unhealthy. They are just not as toxic and unhealthy as tobacco products, with one exception of e cigarettes that enable voltage adjustment to five or six volts. Jensen, Lou, Pankow, Strongin, and Peyton, (2015) reported in the March issue of The New England Journal of Medicine that such devices at full voltage produce four times the formaldehyde released by smoking tobacco. However, they also report that the amount released by standard e cigarette devices fall between 300 and 750 times lower than smoking a pack of cigarettes a day.  

People have begun to question zealous, factually-correct, but marginally-relevant junk science studies. Nocera challenged the findings of Jensen et al. (2015), pointing out that they failed to highlight the fact that high levels of e cigarette voltage makes the vapor taste extremely bitter, and therefore, it is unlikely to lead to frequent use. 

Last fall I was chatting with Mark (not his real name), who was doing some repair work on my house. Mark was regularly inhaling his e cigarette, as he said he has been for the past six months, at forty milligrams a day. As Mark was a recovering heroin addict, I was concerned about the risk of nicotine ingestion on his ability to remain drug-abstinent. I asked if he planned to use the e cigarette to get totally drug-free. Although the reply was “eventually,” it was clear from our conversation that the switch from tobacco was motivated mostly by the freedom to continue dosing without social stigma. If Mark eventually gets nicotine-free, then he will have helped to reduce the odds of relapsing to drug abuse. In that case, e cigarettes will not be a wolf in sheep’s clothing. Only time will tell.

Although the jury of scientific opinion remains cautious, mounting evidence suggests that e-cigarettes offer a relatively safe and effective path to reducing nicotine intake via tobacco smoking—perhaps eventually achieving self-sustainable abstinence. Should smoking clients recovering from addiction to drugs other than nicotine be encouraged to try e-cigarettes if previous quit attempts have failed? Generally, yes. Research reports in the past two years indicate that they are equally or more effective than competing methods. Should smoking clients be discouraged from using e-cigarettes? Definitely not. However, they should be regularly encouraged to experiment with reduced dosage to help kick the smoking habit and thereby improve the odds of sustaining abstinence from alcohol and other drugs to which they are addicted. If other aids have not been working for a smoking client, there is no evidence to date that e Cigarettes are more harmful or less effective than NRT or will power, a point echoed by Grana, Benowitz, and Glantz (2014).  

Abrams, D., Axell, T., Bartsch, P., Bauld, L., Borland, R., Britton, J., . . . Yach, D. (2014). Defending proper science and evidence: Our second letter to the WHO, exposing mis-presentation of evidence in Glantz letter. Retrieved from http://www.ecigarette-research.com/web/index.php/2013-04-07-09-50-07/2014/168-who-letter2 

Adkison, S. E., O’Connor, R. J., Bansal-Travers, M., Hyland, A., Borland, R., Yong, H. H., . . . Fong, G. T. (2013). Electronic nicotine delivery systems: international tobacco control four-country survey. American Journal of Preventive Medicine, 44(3), 207–15.

Brown, J., Beard, E., Kotza, D., Michie, S., & West, R. (2014). Real-world effectiveness of e-cigarettes when used to aid smoking cessation: A cross-sectional population study. Addiction, 109(9), 1531–40. 

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Chapman, S. (2014). E Cigarettes: Does the new emperor of tobacco harm reduction have any clothes? European Journal of Public Health, 24(4), 535–6.

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Goniewicz, M. L., Kuma, T., Gawron, M., Knysak, J., & Kosmider, L. (2012). Nicotine levels in electronic cigarettes. Nicotine & Tobacco Research, 15(1), 158–66. 

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Nocera, J. (2015).  Is vaping worse than smoking? The New York Times. Retrieved from http://www.nytimes.com/2015/01/27/opinion/joe-nocera-is-vaping-worse-than-smoking.html

O’Connor, L. (2014).  E cigarettes could face major bans in California. The Huffington Post. Retrieved from http://www.huffingtonpost.com/2015/01/26/california-e-cigarette-ban-vaping_n_6551336.html

Pulvers, K., Hayes, R. B., Scheuermann, T. S., Romero, D. R., Emami, A. S., Resnicow, K., . . . Ahluwalia, J. S. (in press). Tobacco use, quitting behavior, and health characteristics among current electronic cigarette users in a national tri-ethnic adult stable smoker sample. 

Siegel, M. B. (2015).  The misbegotten crusade against e Cigarettes. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/michael-b-siegel-the-misbegotten-crusade-against-e-cigarettes-1424821708

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Wetzstein, C. (2014). Study finds teens flocking to e cigarettes. The Washington Times. Retrieved from http://www.washingtontimes.com/news/2014/dec/15/e-cigarettes-increasing-in-popularity-among-teens-/?page=all

Wieczner, J. (2013). Ten things e-cigarettes won’t tell you. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/SB10001424052702304448204579184052293918312