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E-Cigarettes: The Questions Still Burn

Meanwhile, more smokers get hookah on a feeling

By Yadira Galindo   |   March 04, 2014

If you’ve walked into a bar and find yourself transported to a scene from Alice in Wonderland, you’ve probably entered a hookah bar. These establishments – and folks “smoking” e-cigarettes indoors – are becoming increasingly commonplace, despite hard-won progress in tobacco control.

In January, the American Cancer Society reported that cancer deaths declined by 20 percent between 1991 and 2010, saving more than 1.3 million lives. Part of the reason attributed for the decrease was a dramatic decline in cigarette smoking.



According to the 2014 Surgeon General’s report, cigarette smoking among American adults has dropped from 42 percent in 1965 to 18 percent in 2012. This, according to experts, has resulted in a decline in lung cancer deaths and a drop in all cancer types combined. Still, healthcare professionals are alarmed by recent trends in the use of two alternatives popularly perceived to be safer: hookahs and e-cigarettes.

Hookahs pull burning tobacco smoke through a basin of flavored water. They deliver the same addictive nicotine dose as cigarettes — as well as the same carcinogenic toxicants from burning tobacco and other additives. E-cigarettes are tobacco-less, battery-operated devices that spritz flavored vapor into the mouth.

Shu-Hong Zhu, PhD, principal investigator of the California Smokers’ Helpline, led a 2013 UC San Diego School of Medicine population survey on e-cigarette use before the widespread appearance of major paid advertisements of these products on television. The results showed 75 percent of participants reported having heard of e-cigarettes.

Use of these products has gained swift popularity because of fewer restrictions than cigarettes on who can use them and where. There is also a strong belief among some users that these products are safer, making them more socially acceptable. In addition, producers are creating flavors like bubble gum and peach fuzz, which tend to attract younger consumers.

Zhu and colleagues reported that e-cigarette popularity has been boosted by free media coverage in news reports, cameos in popular movies and endorsements by celebrities who tout them as a tool to quit smoking. During January’s Golden Globes Awards, for example, both Julia Louis-Dreyfus and Leonardo DiCaprio were filmed puffing on the electronic devices.



Because they do not produce a toxic cloud of secondhand smoke, promoters assert they are safe. E-cigarette users, known colloquially as “vapers,” exhale a mixture of volatile organic compounds, heavy metals and ultrafine particles that usually contain aerosolized nicotine in a cloud of vapor.

A Food and Drug Administration analysis of two e-cigarette brands found the products contained carcinogens and traces of nicotine, even in those labeled nicotine-free. The majority of e-cigarettes contain nicotine, which can cause adverse health effects like elevated blood pressure and heart disease, said John P. Pierce, PhD, professor in the Department of Family and Preventive Medicine and director for population sciences at UC San Diego Moores Cancer Center.

“The argument is that e-cigarettes do not contain the hundreds of known carcinogens that combusted tobacco product do,” said Pierce. “But analyses of e-cigarettes show they do contain carcinogens, albeit less than cigarettes. There is no known safe level of these carcinogens.”

Wael Al-Delaimy, MD, PhD, professor and chief of the Division of Global Health in the Department of Family and Preventive Medicine at UC San Diego, said the products are too risky to be on the market and supported by public health professionals.

“There are about 250 brands of e-cigarettes with no control over quality,” said Al-Delaimy. “There are no real studies to show that the benefit of using these products outweighs the risks.”

Despite concerns by experts like Pierce and Al-Delaimy, e-cigarette and hookah use is rising unabated. A 2011 study by Al-Delaimy showed that between 2005 to 2008 hookah use among all adults increased by more than 40 percent.

Data from the 2012 National Youth Tobacco Survey shows that e-cigarette use has nearly doubled among high school students from 1.5 percent to 2.8. Hookah use has risen from 4.1 percent to 5.4 percent. For Al-Delaimy, this is troubling.

“The main risk of these products is introducing cigarettes to youth or those who wouldn’t have smoked the combustion cigarettes but find the e-cigarettes a trendy thing and might move to using actual cigarettes,” he said.

Pierce, whose research is cited as a major reason for the marketing restrictions in the 1998 Master Settlement Agreement between the state Attorney’s General and the Tobacco Industry, said he has not seen such marketing tactics, like using kid-friendly flavors, since cigarette advertising was banned from television. Like the old tobacco ads, he said, the new commercials portray e-cigarettes as sexy and glamorous with celebrity spokespeople.

“They are using 50s-style marketing using NASCAR, cartoons and television,” said Pierce. “This is about addicting new generations because people are dropping cigarette use.”

According to the American Cancer Society, tobacco use remains the single-largest preventable cause of disease and premature death in this country. It costs the United States $193 billion annually in health costs and productivity loss.

Proponents of e-cigarettes say these products could help smokers quit smoking. Zhu's study found that smokers who are using e-cigarettes are indeed more likely to have made a quit attempt than those who are not using e-cigarettes. However, “There has been no study suggesting that e-cigarettes coming to the market has led to any detectable change in the quit attempt rate at the population level,” wrote Zhu and colleagues in their study.

Pierce agrees. He said quitting is the most important thing smokers can do to improve their health, but he says existing scientific evidence suggests smokers who use e-cigarettes are less, not more, likely to quit.

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