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E-Cigarette bans warranted amidst scientific uncertainty

With NSW passing laws restricting the sale of electronic cigarettes and accessories to people under 18, Wendy Zukerman takes a look at the science: are e-cigarettes a great way of helping smokers quit or a dangerous new moneymaking attempt from the tobacco industry?

The sale of electronic cigarettes to minors is now banned in New South Wales after new anti-e-cigarette laws came into effect this week.

According to NSW Health Minister Jillian Skinner, the legislation was a priority for the government. ‘Following our re-election in March, we moved immediately to ban the sale of e-cigarettes and e-cigarette accessories to minors,’ she says.

There is no question that taking a puff on an e-cigarette is less dangerous as taking a puff on a cigarette.

After decades of anti-tobacco messages and smoking laws, e-cigarettes are fast becoming big business. Data out this year from the Centre of Disease Control found that two million students in the US have used them.

‘In the US now, there are more kids who are vaping than who are smoking,’ says Simon Chapman, a professor of public health at the University of Sydney.

Meanwhile, the American Heart Association’s Policy statement notes that unregulated e-cigarette use ‘has the potential to erode gains in smoking cessation and smoke free laws’.

Things might not be so black and white, though. Some scientists advocate the use of e-cigarettes as a tool to wean people off tobacco.

E-cigarettes use a battery to heat up a liquid, usually propylene glycol or glycerol. Often the liquid contains nicotine. When the concoction is heated it turns into an aerosol that can be inhaled. The product provides the user with the nicotine buzz of a cigarette without burning tobacco.

Many e-cigarettes are also sold with a choice of flavours such as apple, strawberry and bubblegum. With sharp memories of Fred Flintstone being used to pimp cigarettes to children in the 1950s, these seemingly child-friendly flavours have rubbed health experts up the wrong way.

Still, e-cigarettes are safer than smoking tobacco. ‘There is no question that taking a puff on an e-cigarette is less dangerous as taking a puff on a cigarette,’ says Stanton Glantz, professor of medicine at the University of California in San Francisco.

This is because the toxicity of a cigarette largely stems from the thousands of chemicals released when tobacco burns—a process that doesn’t occur in the electronic version.

A review conducted by Glantz and colleagues and published last year found that the level of toxic compounds in e-cigarettes can be hundreds of times lower than those found in regular cigarettes.

However, while they’re less dangerous than tobacco, e-cigarettes are unlikely to be harmless. ‘The danger of cigarettes is so stratospherically high,’ says Chapman. ‘It’s like comparing the 15th highest mountain in the world to Mount Everest.’

Professor Stanton Glantz, agrees: ‘You’re inhaling a lot of toxic chemicals when you use an e-cigarette.’

The heating devices in e-cigarettes can emit heavy metals. Additionally, when the temperature of propylene glycol rises past a certain point it can form the toxic chemical formaldehyde.

Glantz is also concerned about ultrafine particles produced once the liquid inside an e-cigarette is heated. ‘Those ultrafine particles are themselves dangerous,’ he says.

According to Glantz, these particles, which are about 1/50th the width of a human hair, can move through the air sacs in the lungs and into blood. Once in your system, Glantz says, these products cause inflammation, which can trigger systemic biological processes that affect the blood and the lining of the arteries, increasing the risk of cardiovascular disease.

Currently, however, there is little evidence that the tiny particles in e-cigarettes specifically cause any of these problems.

‘It’s extrapolating from what we know about ultrafine particles in general,’ says Glantz.

E-cigarettes are a relatively new product, and there are no long-term studies into their health effects. This is particularly problematic given that many of the diseases associated with conventional cigarettes, such as cancer and heart disease take a long time to develop.

‘We are going to have to wait a while to know precisely how bad they are,’ says Glantz.

Still, scientific opinion is divided when it comes to just how fearful we should be of the potential dangers. Dr Lynne Dawkins, leader of the Drugs and Addictive Behaviours Research Group at the University of East London, acknowledges that there are harmful chemicals in e-cigarettes, but says we need to put that into perspective, particularly since e-cigarettes are likely to be less dangerous than conventional cigarettes.

‘There are harmful chemicals in everything: in the air we breathe, in the food we eat, in the nail polish aroma that we put on our toe nails,’ says Dawkins, who has received funding from several electronic cigarette companies.

Simone Davis, who works for Liberty Flights, an e-cigarette company, says that in the face of uncertainty her company chooses products that are ‘approved for human consumption’.

But Chapman warns that there is an important difference between inhaling and consuming products. ‘These have not been approved for inhalation, let alone 200 times a day, 365 times a year,’ he says.

For example, the butter-flavoured chemical diacetyl is often added to foods such as popcorn. It has also been found in butterscotch flavoured e-cigarettes. While approved for human consumption, diacetyl can cause a rare but serious and irreversible lung condition called bronchiolitis obliterans, or ‘popcorn workers lung’ when inhaled.

There’s also a debate about whether nicotine itself is dangerous. Dawkins describes nicotine as ‘a mild stimulant, like caffeine really’. While Glantz says that nicotine ‘actually changes the physiology of the brain and inhibits a lot of normal neural development’.

According to Chapman, it’s hard to say whether nicotine is all that harmful on its own because most people who suck up high levels of nicotine over long periods of time are tobacco smokers—making it tricky to separate its effects from those of other chemicals. ‘We really don’t know enough to know about if it’s in itself dangerous,’ he says.

Meanwhile, uncertainty exists over whether e-cigarettes effectively pull smokers away from conventional cigarettes. ‘They can help people quit smoking,’ says Professor Chris Bullen from the University of Auckland, whose work has shown that e-cigarettes can be at least as effective as nicotine patches at helping people quit.

But Glantz has a different take. ‘The most dangerous thing about e-cigarettes is that they keep people smoking cigarettes,’ he says. To make his case, he cites different data from Bullen’s, which suggests that smokers using e-cigarette are less likely to quit.

Glantz says this could be because many countries let people use e-cigarettes in places they couldn’t smoke tobacco. ‘The main motivators, and one of the things that really helps people quit smoking, is smoke-free laws, and smoke-free homes,’ he says.

Chapman says he will await more evidence before making up his mind on the issue. ‘E-cigarettes could be a revolutionary breakthrough for smoking cessation, but at the moment the evidence on cessation is pretty disappointing, they are nothing like the hype is suggesting,’ he says.

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