E-cigarettes? Viable alternative to smoking?

Let me start by saying smoking is bad. You shouldn't do it. Period. I wouldn't be doing my due diligence as a physician if I didn't say that out front. Now that we've established that, let's talk about e-cigarettes.

Why does this matter for pediatrics? Simple. Second-hand smoke is a serious problem with kids, to the point where it can severely damage their overall health, especially if they have diseases like asthma. So, at every single well-check, we ask about smoke exposure. Most people I've dealt with seem to have gotten smart and are at least limiting smoking to outside and not in the car. This is a huge reason why there has been such an effort at eliminating smoking in the workplace.

Enter e-cigarettes. They were developed in the early 2000's as an alternative to smoking. Essentially, there's a liquid cartridge with nicotine and other staff that is heated by a coil and inhaled by the smoker.

Lots of concern about e-cigarettes has hit the news recently. So much that one blog post probably won't do it justice, but at least I can attempt to hit the high points. So, let's play a game of myth or fact?


1. E-cigarettes reduce smoking.
Myth.

One study done in September demonstrates a very small percentage of people were more likely to quit using e-cigarettes vs nicotine patches. The effect was very small, with only 1.5% more e-cigarette users quitting after 6 months. What's more, the confidence intervals (CI) crosses 0, which means the difference wasn't really a difference.

Another study in JAMA Internal Medicine shows a similar result: no difference in quitting between users of e-cigarettes and users of conventional cigarettes.

However, a study done in JAMA Pediatrics that hit the press earlier this month shows that e-cigarette use has doubled in teens in the past few years, and about half of current e-cigarette users also smoked conventional cigarettes. In fact, those who smoked conventional cigarettes were more likely to have tried e-cigarettes in the past. This goes against the claim that e-cigarettes are good for quitting smoking.

The increased usage might have something to do with the fact that while ads for cigarettes have been banned for 40 years, there is no ban in place for e-cigarettes, so an ad for such a device actually ran during the Super Bowl this year. It doesn't help that only about half states have bans against minors buying e-cigarettes, and there is relatively little attention to buying them online.


2. Second hand exposure from e-cigarettes is better than regular cigarettes.
True.

A review looking at several studies examined this question from the perspective of occupational health. That is, if an industrial worker was exposed to the same chemicals in the vapor of an e-cigarette, would this worker be at a higher risk of disease. They did negate the nicotine, since it is legal and the smoker is already voluntarily consuming more than the recommended exposure limit by using the device. It was the secondary exposures that they specifically wanted to look at.

The primary chemicals exposed to with e-cigarettes are propylene glycol and glycerin, which do not have known exposure thresholds, and volatile organic compounds. Polycyclic Aromatic Hydrocarbons are most of the cancer-causing chemicals in cigarettes; these were not found in most vapors.

I don't think anyone doubts that e-cigarettes produce fewer chemicals than regular cigarettes, thus reducing second-hand exposure. What seems to be the big debate right now, and the subject of e-cigarette bans in places like Los Angeles, is whether there is ANY risk for e-cigarette exposure, and the public health implications of encouraging e-cigarette smoking in public.


3. E-cigarettes are safer.
Generally true, as alluded to above, with a few exceptions.

Nicotine in cigarette form is relatively difficult to ingest. Smoking is the best way to do this. However, as I mentioned earlier, the nicotine for e-cigarettes is in liquid form. That makes it much easier to either drink or absorb through the skin, which could cause serious harm, especially to children. The number of calls to poison control centers related to the nicotine liquid went up 300% in 2013.

Why is it so dangerous? Well, nicotine is similar to a chemical naturally used by the body at the point where either two nerves meet or a nerve meets a muscle. That means it can cause any amount of damage to the brain, the spinal cord, and to muscles. Commonly, it affects the GI tract first, and the person gets vomiting, but if it is not caught early, it can result in seizures or other problems with the brain. In a small child, it doesn't take a lot of nicotine to have this effect.


Bottom line is that while e-cigarettes are safer than conventional cigarettes, we don't know the long-term effects of e-cigarettes because they are so new, and they do have unique safety concerns. It took a good 20-30 years before we saw lung cancer deaths spike from the cigarette usage in the 1960s, and it's very possible we'll see a similar rise 20-30 years down the line from e-cigarettes. But maybe not. As I'm pretty sure e-cigarettes are cheaper and generally less toxic, I'd encourage people who are smoking to switch to them, but that doesn't mean I'd encourage their blanket marketing.

Until then, I'll hold to my general recommendations: Don't smoke around kids. Don't smoke indoors or in the car. And when you do smoke, wear a jacket that can be removed when you are done, so you don't bring those chemicals inside with you.