E-Cigarettes: Expert Q&A With the CDC
By Julie Edgar
Reviewed by Arefa Cassoobhoy, MD, MPH
"Vaping" is a new form of inhaling nicotine that the CDC would like to seriously curb.
It's what you do with an e-cigarette, and it's gaining in popularity. The battery-powered cylinders deliver nicotine with a puff of hot gas, minus the smoke.
E-cigarette use doubled among middle and high school students, along with adult smokers, from 2011 to 2012, the recent National Youth Tobacco Survey found. Altogether, in 2012, 1.78 million middle school and high school students had tried e-cigarettes. Three quarters of the students who used e-cigarettes in the previous 30 days also smoked cigarettes during the same period.
The federal government has no authority to regulate e-cigarettes, although that is expected to change soon. The FDA has proposed rules that would allow it to regulate them like other tobacco products.
Tim McAfee, MD, talks to WebMD about why the agency is concerned about their growing use, despite a lack of research on the health risks. McAfee is the CDC's director of the Office on Smoking and Health.
Q: What do you find most alarming about the findings of the National Youth Tobacco Survey?
A: We don't like to see kids using any form of nicotine, because nicotine is not a good thing for a developing adolescent brain. ... It's introducing them to a behavior that is very similar to smoking. The thing that got them interested was mass advertising that glamorizes the act of vaping. It looks comparable to smoking. We're worrying that the line of separation of smoking e-cigarettes and cigarettes is sufficiently vague, and it will result in more kids smoking.
Q: What do you make of the University of Oklahoma study (researchers surveyed 1,300 college students -- average age 19 -- about their tobacco and nicotine use) that found that electronic cigarettes are not a gateway to cigarette smoking? That the majority of students who were asked said they used them to quit conventional cigarettes?
A: It's not really relevant to adolescents. It was conducted in college students, average age 19. Until it's peer-reviewed and published, it shouldn't be something used to make policy decisions about whether or not (e-cigarettes) have an impact on kids.
Q: But is it bad if people use electronic cigarettes as a nicotine replacement product, a way to quit smoking?
A: It's illegal for e-cigarettes to be marketed as a smoking cessation aid. A [U.S. District Court of Appeals] judge said if they make medical claims, like the product helps people quit smoking, they'd need to go through a formal FDA process.
In the meantime, there are implied claims and a lot happening in social media, but most of the marketing is taken from the cigarette marketing playbook of 40 years ago -- as sexy and glamorous, a form of rebellion, and as a way to get around secondhand smoke laws. It's working, unquestionably, because we've seen the doubling of use among adults. We certainly think we have enough evidence that if someone switched from a pack of cigarettes to e-cigarettes, it would likely be an improvement in their health. However, it's important to realize the majority of smokers in the U.S. who experiment with these e-cigarettes continue to smoke and use e-cigarettes sporadically in social situations where they can't smoke.
Q: The CDC says e-cigarettes have far fewer toxins than conventional cigarettes, so why issue warnings?
A: There are 250 brands of these e-cigarettes and they're completely unregulated, so what is in one may be different than another. Some have small levels of cancer-causing chemicals, some don't.
The more important thing is that people will be exposed to nicotine. ... Nicotine is addictive. ... It's not a benign chemical.
Q. Is nicotine by itself a harmful substance?
A: Nicotine is not the main ingredient in cigarette smoke that is harmful.
Nicotine's main "harm" is that it is a psychoactive chemical that is the primary driver of a smoker's desire to continue smoking cigarettes. Smokers become addicted to it, and continue to crave smoking and suffer withdrawal symptoms when they stop.
Nicotine does have some direct harms that we know about. In general, these are less-well understood than the effects of tobacco smoke, because until recently most people got their nicotine from cigarettes. However, we know that nicotine contributes significantly to the harms to the developing fetus, probably through direct effects on the placenta as well as from passing across the placenta into the fetus. Some of this is likely related to how nicotine acts to constrict blood vessels.
Another significant concern is the effect of nicotine on the developing adolescent brain, which will develop differently under the influence of nicotine than without it.
Q: What might FDA regulations look like?
A: I can't comment because they're a sister agency, but it's in nobody's interest to continue in the Wild West state we're in, where they can be sold to anybody, including adolescents, in half the states. There are no required manufacturing standards and they can market them as if they were peanut butter or something. It doesn't mean (e-cigarettes) will be treated just like cigarettes, because they're not, but they're a product that contains a psychoactive addictive ingredient.
Q: We know how many teens have tried e-cigarettes but not how many use them regularly. When will that data be collected?
A: We'll ask that in the 2013 survey. [The number of teens using e-cigarettes] will be smaller, but it's still not going to be inconsequential. It'll be tens or hundreds of thousands of kids who've used them more than once in the last 30 days.
We've found from 20 years-plus experience that if a child or adolescent has used a cigarette in the last 30 days, that is very predictive of future cigarette use. We fear the same will hold true with e-cigarettes. Most of what we know of substance abuse patterns makes us worry this will turn out to be the case.
Q: Any new research on the effects of e-cigarettes?
A: I am not aware of any. It would be extremely difficult to do currently because ... in terms of long-term health effects, it takes decades to look at the effects we're talking about. At one level we're trying to get the question into the great national surveys so we'll be able to make sense of this 10, 20 years from now. We have to rely on what we know of toxicology, that what comes out of e-cigarettes is less toxic, but it's more toxic than breathing clean air. That's our preferred modality for breathing.
SOURCES: News releases, CDC. WebMD News from HealthDay: "E-Cigarettes May Not Be Gateway to Smoking: Study." CDC: "About one in five U.S. adult cigarette smokers have tried an electronic cigarette." Tim McAfee, MD, MPH, director, CDC Office on Smoking and Health. FDA: "Regulation of E-Cigarettes and Other Tobacco Products." Jenny Haliski, FDA Office of Media Affairs.