Even the writing of the above “product” as a title offends
me. For those who have managed to bypass the tsunami of people walking the
streets/sitting on public transport/your favourite restaurant with what looks
like a tiny musical flute sticking out of their mouth, e cigarettes are the new
“cool” way to smoke.
They are advertised as being the best thing you can do for
your health and from the sheer volume of marketing bumph surrounding them you
would think they were some sort of miracle that purified even the finest
mountain air.
In this blog post I will therefore attempt to work out
1) What
the hell they are
2) What
the hell is in them
3) Why
the hell people think it is acceptable to use them like a lollipop
The premise of the e cigarette is that it is supposedly a
healthier alternative to regular cigarettes because they do not contain
tobacco. This sounds all well and good as we know the damage that tobacco can
cause – in particular reference to my area of “expertise” it can lead to a
whole range of oral cancers which can involve not just the areas of your mouth
visible when you yawn but a whole realm of other areas in the head and neck. Most
brands of this device also claim that they do not contain tar. Another benefit
of course unless of course you wish for your lungs to look like the surface of
the M6.
They were primarily designed as an addition to the realms of
nicotine replacement therapy (NRT) alongside patches, gum, medication like
Champix etc and therefore used to cut down smoking.
All of this sounds very positive, so much so that one lady
who switched to using a certain brand of the e cigarette to write the poem
below:
No more cigarettes for me
What could I do, I liked the taste
Went to e-cigarette with much haste
What could I do, I liked the taste
Went to e-cigarette with much haste
Cigarettes without the bad bits
Made it easy to kick the habit
They come in lots of different flavours
For me to try and quickly savour
Made it easy to kick the habit
They come in lots of different flavours
For me to try and quickly savour
The
prices are great
Delivery is never late
So give Smokers Angel a go
And try their range of Halo
Delivery is never late
So give Smokers Angel a go
And try their range of Halo
Now that
is quite a gushing testimonial. Similarly, the woman below appears extremely
pleased with her e cigarette. It has even managed to get her a gentleman
willing to photobomb her holiday snaps.
What could possibly be so bad.
On
that note, let’s see if we can find any information at all about what is in
them. Now trust me, I spent a good few hours trying to research this and the
only thing I consistently came across was marketing BS. So I turned to the BMA
(as I so often do)
What are they?
“E-cigarettes
are battery-powered products designed to replicate smoking behaviour without
the use of tobacco – some look like conventional cigarettes, while others
appear more like an electronic device” They consist of
a cartridge containing liquid nicotine, an atomiser (heating element), a rechargeable
battery, and electronics.
E-cigarettes
have been marketed as cheap and healthier alternatives to cigarettes as well as
to look and feel like cigarettes for use in places where smoking is not
permitted since they do not produce smoke.
E-cigarettes are products operated by a single use or rechargeable battery that
heats a liquid based solution (often containing nicotine) into a vapour. This
is then inhaled by the user, simulating the effect of cigarette smoking.
They
are primarily used (apparently) as a means to quit smoking and therefore the
major studies conducted on e-cigarettes have analysed nicotine content, as
addiction to this apparently why people cannot quit smoking. “An
analysis of the total level of nicotine generated by e-cigarettes which
vaporise nicotine effectively found that the amount inhaled from 15 puffs was
lower compared with smoking a conventional cigarette”. Please note the
extremely vague wording used by the usually extremely un-vague British Medical
Association. Another study analysed sixteen
e-cigarette brands and found the total level of nicotine in vapour generated by
20 series of 15 puffs varied from 0.5 to 15.4 mg. Again, there is no regulation,
nor any standard or reproducible results that can be produced from e cigarette
testing.
In 2009, the
United States Food and Drug Administration (FDA) released results of an
analysis of some
e-cigarette product, it showed that the tested e-cigarette cartridges contained
carcinogens and toxic
chemicals. Analysis of two leading brands by the FDA also revealed:
- • diethylene glycol (a toxic chemical) in one cartridge at approximately 1%
- • tobacco-specific nitrosamines (which are human carcinogens) in half of the samples
- tobacco-specific impurities suspected of being harmful to humans (anabasine, myosmine, and ßnicotyrine) in a majority of the samples
The
tests also suggested that quality control was inconsistent or non-existent:
- • cartridges with the same label emitted a markedly different amount of nicotine with each puff
- • one high-nicotine cartridge delivered twice the amount of nicotine compared to a nicotine inhalation product approved by the FDA.
i.e. the biggest food and drug regulatory
body in the world cannot conclusively say that is in the products or what they
give out.
See next subheading.
E cigarettes – the new enemy?
Whilst I absolutely cannot deny that any improvement on
smoking normal cigarettes is beneficial to health in general and therefore oral
health, e cigarettes are a dangerous realm to enter into.
The reason they are cheaper is because they are not taxed in
the same way as regular cigarettes. Hurray, I hear you shout. Sadly, these
taxes pay my wages in the NHS, they also put people off smoking because it
makes it so darn expensive. Without this deterent what is to stop people
continuing to pump dangerous chemicals into their bodies. Similarly, they are
not regulated in the same way as normal cigarettes. For cigarettes to be sold
they have to go through rigorous quality control, the same does not apply for e
cigarettes. Due to this, we have absolutely no clue what is in them.
All
that can be said is that they are not licensed as a medicine in the UK, and
there is no peer-reviewed evidence that they are safe or effective for the
purpose of helping to cut down smoking, as a “healthier” alternative to smoking
or in fact any other reason except making you look like you’re smoking a marker
pen.
The
World Health Organisation document (which is 50 pages long I might add); WHO
STUDY GROUP ON TOBACCO PRODUCT REGULATION raises further concern about the use
of these products as nicotine replacement therapy. “Delivery of nicotine to the
lung raises concern about safety and addiction that go beyond that related to
currently approved NRT, concern…is associated with the probable exposure of the
lung to repeated dosing, perhaps hundreds of times a day for many months, if
these products are used as a smoking cessation aid, or for years, for smokers
who use them as long-term cigarette substitutes”. That is to say, the delivery
of nicotine directly to the lungs has never before been studied, and whilst manufacturers
get away with using certain chemicals in e-cigarettes because they approved for
human consumption, we have no idea of the effect they have when inhaled.
Most people who purchase and use e-cigarettes claim they do
so as a means to cut down on smoking i.e. smoking cessation, instead of things
like patches, gum and so on. Sadly, the World Health Organisation(WHO) who
govern most of what we do in terms of medication, health choices, prevention
etc state that “as of July 2013, the efficacy in using electronic cigarettes to
aid in smoking cessation has not been demonstrated scientifically”. They tend
to err on the side of caution as they are such a huge body of people of
differing backgrounds and motivations that having a strong unified opinion on
something is a difficult task. However, so unified was their opinion in this
case that they recommend "consumers should be strongly advised not to
use" electronic cigarettes until a reputable national regulatory body has
found them safe and effective”. Nuff said.
The British
Medical Association have also been forced to offer up an opinion on the damn
things and their summary is not much more positive than the WHO. They state
that “four out of five e-cigarette users continue smoking, and use
e-cigarettes primarily as a substitute where smoking is not allowed” thus
completely defeating the object of switching to e-cigarettes for a smoking cessation
purpose. Again, the BMA agree, expressing their concern that e-cigarettes may
undermine smoking prevention and cessation, as
their use is likely
to reinforce the normalcy of the smoking behaviour”.
This normalcy was nicely
illustrated just last week when I walked past a patient sitting IN THE DENTAL
HOSPITAL WAITING ROOM smoking one of these devices, regarding me with confusion
at my anger with her behaviour. Similarly, the fact that the e cigarettes are
generally quite aesthetically pleasing and gadgetty-looking means that people
are far more likely to openly smoke them, and thus consume more nicotine than
they would should they smoke their normal cigarettes, thus negating the
intended purpose of switching.
Our
Australian cousins also echo this. “Other unintended consequences of
e-cigarette use include the potential to induce nicotine addiction in non-
smokers or maintain addiction in current smokers who might otherwise quit. Furthermore,
concerns have been raised that e-cigarettes may undermine the comprehensive
indoor smoking restrictions and
smokefree air policies” and making it generally acceptable for people to be
seen smoking after years of hard work aiming to make them feel as embarrassed about
smoking in public as public urination – people still do it but its few and far
between, although maybe I grace the wrong areas of town at the wrong time of
night.
The
National Institute for Health Care and Excellence (NICE) recently published new
public health guidance backing the use of licensed nicotine products to help
people cut down as well as stop smoking. However, these guidelines did not
cover e-cigarettes. Again, without having to say it, I imagine several suited
men sitting round a table and laughing at the concept of e-cigarettes even
being considered in this category of something that they would advise or
recommend as something of health benefit.
Now
of course, I cannot complete an analysis of the use of this product without
referring to the superpowers of the USA – namely the Food and Drug Administration
department (FDA). They basically regulate everything that is consumed, injected
or applied by our friend across the pond and thus you could argue, have
probably become fairly used to seeing products come and go, and are unlikely to
have any emotional response related to items they are asked to assess. So
strongly therefore did the FDA feel about e cigarettes that way
back in 2010 long before the e cigarette phenomenon reached our shores, they
issued warning letters to a grand total of 5 electronic cigarette distributors
for various violations of the Federal Food, Drug, and Cosmetic Act (FDCA)
including unsubstantiated claims and poor manufacturing practices. What is
more worrying is that the FDA only regulates products intended for therapeutic
use i.e. as a nicotine replacement therapy, and therefore, if a company decides
to purely register their e cigarette product as recreational, or a hobby based
item, then it completely negates all regulation by any drug agencies. Still
fancy puffing away on one of them?
Dental Impact
What most people don’t consider is the effect that smoking
has on their mouth. Whilst smoking e cigarettes should technically reduce risk
of oral cancer, the presence of carcinogens in most of the leading brand’s e
cigarettes negates this benefit. Similarly, the main causative factor of
smoking related gum disease is nicotine. As the e cigarettes are rammed with
the stuff, they offer no benefit in terms of “the leading cause of tooth loss”
(thanks Corsodyl). That is to say, puffing away on your e-cigarette is just as
harmful to your gums as smoking regular cigarettes and so your path on the road
to dentures is just as speedy. In fact the WHO state that 90% of the nicotine
that people smoking e-cigarettes are so desperate to get into their lungs, is
actually deposited in the mouth.
In Summary.
The
Medicines and Healthcare Products Regulatory Agency in the United Kingdom
reported that it planned to regulate e-cigarettes as medicines from 2016 when
new European tobacco laws come into force so until then, it remains that we
have no idea what e-cigarettes are. In my mind, used as a nicotine replacement
therapy, i.e. to smoke less and less over a set period until smoking has been stopped,
completely, is fine, so long as they smoke it miles away from me, not around
children, and that the whole thing stops being glamorised.
What I trawled through in order to write this blog:
BMA, E-cigarettes
in public places and workplaces A
briefing from the BMA Occupational Medicine Committee and the Board of Science,
March 2012
BMA calls for stronger regulation of e-cigarettes
March 2012 (updated January 2013) A briefing from
the Board of Science and the Occupational Medicine Committee
WHO "Questions
and answers on electronic cigarettes or electronic nicotine delivery systems
(ENDS)". World Health Organization. 9 July 2013.
