Understanding the risks of electronic cigarettes

  • Published
  • By Terri Jordan
  • 81st Aerospace Medicine Squadron
I remember when I first heard about electronic cigarettes. Shortly after starting my current position as the health promotion manager in 2011, I was teaching a tobacco cessation class when one of the participants starting talking about using e-cigarettes. I said to myself, "What's an e-cigarette?" The past two years have been a crash course in better understanding e-cigarettes - the latest trend in nicotine delivery.

E-cigarettes are battery-operated products designed to deliver nicotine, flavors, and other chemicals as a vapor that is inhaled by the user. This is known as "vaping." While e-cigarettes have been advertised as a "safer" alternative to conventional cigarettes, potentially harmful constituents, including nitrosamines, diethylene glycol and animal carcinogens have been found in them. The take-home message is that not enough is known about the long-term safety of e-cigarettes to definitively state that they are safe.

E-cigarettes have been around since 2003, and they are a rapidly growing business. In 2008, total e-cigarette revenues were $20 million; the projection for 2013 is $1 billion Each $4 e-cigarette cartridge is the equivalent nicotine hit of two packs of cigarettes. By comparison, cigarettes can run $5-10 per pack, so e-cigarettes may be a cheaper way to feed the nicotine addiction. "Big Tobacco" has recognized the growth potential of e-cigarettes. E-cigarettes currently operate in a regulatory vacuum. In 2010, the Food and Drug Administration attempted to ban e-cigarette imports on the grounds that they were unapproved pharmaceutical products that deliver nicotine. Unlike dietary supplements, a pharmaceutical product must undergo pre-market approval. The courts determined that e-cigarettes could not be regulated as a pharmaceutical product, but they can be regulated as a tobacco product. However, FDA has yet to issue any regulatory guidance on e-cigarettes. So currently, you may see e-cigarettes sold to minors, advertised widely, marketed without warning labels and not subject to the level of regulation as we see with conventional cigarettes. At the local level, there is not much consistency in whether e-cigarettes are subject to tobacco use bans.

We don't have trend data on e-cigarette use in the Department of Defense. In the 2011, DOD Survey of Health Related Behaviors, e-cigarette use was included for the first time. Similar to cigarette use, the Air Force has the lowest e-cigarette use in DOD, with 5 percent of Airmen reporting ever using an e-cigarette and 2.2 percent reporting use in the past year. The highest use is in the Marine Corps, double that of the Air Force. Air Force data is comparable to the civilian population. In February 2013, the Centers for Disease Control reported that 6 percent of U.S. adults tried e-cigarettes in 2011, double the prevalence from 2010. A similar trend exists among children. During 2011-12, e-cigarette use among high school students doubled from 4.7 to 10 percent. The public health nightmare is that unfettered access to and marketing of e-cigarettes will create a generation of youths hooked on nicotine and lead to greater traditional cigarette or other smokeless tobacco use.

Air Force Instruction 40-102, Tobacco Use, establishes tobacco policy. In the 2011 revision, the Air Force explicitly included e-cigarettes under the definition of tobacco and subjected e-cigarettes to all the restrictions implemented for cigarettes, cigars and smokeless tobacco. The Air Force is the first branch of the service to establish an e-cigarette policy.

There has been pushback from some who claim that e-cigarettes helped them quit cigarettes and should be encouraged rather than restricted. But e-cigarettes should continue to be subject to the same policies as other forms of tobacco for several reasons.

First, the FDA categorizes e-cigarettes as a tobacco product.
Second, the long-term safety of e-cigarettes is unknown. Although e-cigarettes do not contain tobacco, they are nicotine delivery systems and contain other potentially hazardous toxins and carcinogens.

Finally, we need to proceed cautiously because of the second-order consequences of getting more Airmen addicted to nicotine in e-cigarettes, and the very real risk that the addiction will lead to greater use of other tobacco products.

For now, the Air Force position is to treat e-cigarettes as any other tobacco product and base policies in consultation with subject matter experts at the CDC, FDA and U.S. Office of the Surgeon General.

Written with assistance from Col (Dr.) John Oh, Chief, Health Promotion, Air Force Medical Support Agency