E-Cigarettes: A Public Health Conundrum

IQ Solutions

According to the Centers for Disease Control and Prevention (CDC), tobacco use is the number 1 preventable cause of death.

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Cigarette smoking causes 1 out of every 5 deaths in the U.S., and secondhand smoke kills nearly 50,000 Americans each year. This is, without a doubt, a major public health concern that we are all well aware of.


Electronic cigarettes, or e-cigarettes, claim to be a healthy alternative to traditional smoking. E-Cigarettes are small electronic inhalers that vaporize a liquid solution that usually contains nicotine. They are meant to mimic cigarette smoking, without all of the carcinogens found in tobacco—carbon monoxide, formaldehyde, cyanide, and ammonia. There is no tar, no ash, no smoke. Bonus: They are also much less expensive than traditional cigarettes.

Some e-cigarette advocates claim they are an effective smoking cessation tool. They can help people quit smoking by replacing one nicotine delivery method for another, like the nicotine patch or nicotine gum. And like the patch, e-cigarette cartridges vary in the level of nicotine they contain—none, low, medium, and high—allowing for a “step-down” method of weaning from nicotine. E-Cigarette manufacturers are careful not to make this claim, as e-cigarettes are not approved for smoking cessation by the Food and Drug Administration (FDA), but a Google search brings up many anecdotes from smokers saying that e-cigarettes helped them quit or reduce cigarette smoking. And a recent study in the British journal Lancet shows that these claims may be accurate.

Innovation or the Same Old Racket?

Are e-cigarettes a positive innovation for long-term health or just a new way to do drugs? Nicotine increases levels of dopamine in the brain, thereby increasing feelings of pleasure and reward. Long-term use leads to addiction, and when users try to quit, they experience symptoms of withdrawal—including irritability, cravings, and headaches. But nicotine is not a carcinogen.

So, while on the surface it may seem like e-cigarettes are the lesser of two evils, there are still a lot of unknowns and possible negative effects of using e-cigarettes.

  1. E-Cigarettes are unregulated. E-Cigarettes fall under FDA’s purview, but the agency has not yet issued any regulations pertaining to their manufacture or sale. FDA’s Center for Tobacco Products is expected to introduce regulation in October 2013, but implementation likely won’t go into effect for a long time.

  2. Toxic chemicals were found in e-cigarettes. In a small study, FDA found diethylene glycol (antifreeze), nitrosamines (human carcinogens), and other harmful chemicals in e-cigarettes.

  3. We don’t know if e-cigarettes are safe. Since they are currently unregulated, there is no way to know what exactly is in e-cigarettes. Also, the FDA study found that “e-cigarette cartridges that were labeled as containing no nicotine had low levels of nicotine present.”

What’s Old Is New Again

Another layer to this debate is the fact that e-cigarette manufacturers are not subject to tobacco advertising regulations. Tobacco companies have been banned from advertising on television for over 40 years, and more recently, FDA banned them from advertising at or sponsoring athletic, musical, or social/cultural events and selling flavored tobacco. These regulations are primarily in place to prevent tobacco companies from enticing children and young adults to try their products.

However, e-cigarette companies currently enjoy a reprieve from these regulations. They advertise on television and all over the Web, and employ celebrities, such as Courtney Love and Jenny McCarthy, to endorse their products in ads. E-Cigarette companies also sell flavored nicotine cartridges, such as cherry, vanilla, peach schnapps, mint, coffee, chocolate, grape, butter rum, and many more. These tactics seem to be attracting America’s youth. CDC reported that the number of youth who have tried e-cigarettes doubled between 2011 and 2012, with 1 in 10 high school students trying them during 2011‒2012.

Because they are not regulated by FDA, there are no restrictions on the sale of e-cigarettes to minors. Some states are enacting their own laws against selling them to anyone under age 18, but the trend of trying e-cigarettes is growing. Knowing that nicotine is addictive, you can’t help but wonder if e-cigarette companies are targeting children and young adults, like tobacco companies did in the past, to create a consumer base of addicted users.

Big Tobacco Tries To Protect Its Turf

Enticed by $1 billion in projected sales for 2013, the three largest tobacco companies in the United States are launching their own e-cigarette products.

  1. Altria Group, Inc., began selling its MarkTen e-cigarette in August 2013.
  2. Reynolds American, Inc., is rolling out its Vuse e-cigarette this year.
  3. Lorillard, Inc., purchased Blu eCigs in 2012.


E-Cigarettes provide big tobacco with the ultimate example of vertical integration. Tobacco consumers that use e-cigarettes to quit smoking will still be addicted to nicotine and therefore will continue use e-cigarettes. Or, they will taper off their nicotine use, extending their use of such products, instead of going cold turkey.

So, even when someone quits smoking cigarettes, tobacco companies will continue to collect revenue from sales of their e-cigarettes. Also, young people initiating nicotine use with e-cigarettes will more easily transition back and forth between cigarettes and e-cigarettes to get their nicotine, when necessary.

Cancer Versus the Unknown

As public health professionals, we have a difficult decision to make. Do we support (or at least turn a blind eye towards) the use of e-cigarettes since they are not supposed to contain the same cancer-causing ingredients as tobacco and can help people stop smoking? Or, do we condemn their use as a new way for young adults to try and become addicted to nicotine? And, how do we handle all of the unknowns? Tell us what you think in comments.

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