E-cigarettes popular despite health questions

Louisville-area mom Marty Thomas tried to quit traditional cigarettes, over and over again, but couldn't stay away from them until she found electronic cigarettes.

"I smoked for 47 years, and I haven't had a cigarette for two years," said Thomas, who was buying her favorite e-cigarette flavor, mango colada, at Derb E Cigs in Jeffersontown, Ky.

Whether for recreation, smoking cessation or other reasons, using e-cigarettes has become popular — to the chagrin of some public health officials and health advocates.

The products are coming under increased scrutiny because little is known about their safety, youths seem attracted to them and they're not yet regulated by the federal government, although the U.S. Food and Drug Administration has proposed doing so. They turn liquid that typically contains nicotine from tobacco into an aerosol that's inhaled by the e-cigarette user.

Some people would say they're safer because they're not combustible, but "they're not healthy for you; that's the bottom line," said Dr. LaQuandra Nesbitt, outgoing director of the Louisville Metro Department of Public Health and Wellness. "People need to avoid the use of nicotine."

But Troy LeBlanc, owner of Derb E Cigs, said electronic cigarettes are being vilified. He sells e-cigarettes in Louisville and Southern Indiana in addition to Jeffersontown and says they're helping people quit smoking.

Yet, "we're being put in the same boat as tobacco and we're not," he said. "We're the alternative to tobacco."

Health concerns

From 2010 to 2013, use of e-cigarettes more than doubled among U.S. adults, according to a study by researchers at the U.S. Centers for Disease Control and Prevention and Georgia State University. It's estimated that more than 20 million U.S. adults have tried them at least once.

Youths also have taken to vaping, a term that's sometimes used to describe the inhaling and exhaling of e-cigarette vapor. A national study released by the University of Michigan in December found that teens are now using e-cigarettes more than regular cigarettes. And the CDC reported in August that more than a quarter of a million youths who'd never smoked a cigarette used electronic cigarettes in 2013; the number more than tripled from 79,000 in 2011 to more than 263,000 in 2013.

"One of our major concerns is the growing rate of youth that are using these e-cigarettes," and the likelihood that some will go on to try traditional tobacco products, said Stephanie Mayfield Gibson, commissioner of the Kentucky Department for Public Health.

Health advocates also are concerned about the potential for e-cigarette users — of any age — to get hooked on the nicotine and suffer health consequences from it. There also are worries about the public being exposed to e-cigarette vapor, children getting poisoned by the liquid nicotine (through ingestion or skin contact) and the general fear that e-cigarettes will normalize smoking again and be used in tandem with regular cigarettes, not as a substitute.

Sales to minors have been banned in Louisville and at the state level. The Louisville Metro Department of Public Health and Wellness is recommending that e-cigarettes be banned from indoor use in public places, and Metro Councilwoman Vicki Welch said she plans to introduce an amendment to the city's smoke-free law to achieve that goal.

Some businesses and organizations, such as the Jefferson County Public Schools, already treat e-cigarettes the same as conventional cigarettes, said Nesbitt, who has been working with Welch on the amendment. "We want to provide clarification through our policy and make sure that those other businesses who want to implement it in that way understand that the (smoke-free) ordinance will give them the latitude to do so," she said.

Welch said she's concerned about the potential health effects and nuisance of e-cigarette vapor. "If you were next to that (vapor), it would be offensive," she said.

She's also worried about the risk of children getting into the liquid nicotine at home and getting poisoned. Calls to the Kentucky Regional Poison Control Center went from nine in 2012 to more than 160 in 2014, the center's director, Dr. Ashley Webb, said.

Vapor vs. tobacco smoke

The American Heart Association, along with a number of organizations, will be working in 2015 to get an indoor smoking ban passed by the Kentucky Legislature to prohibit conventional smoking and the use of e-cigarettes in workplaces and public places, according to Tonya Chang, a senior director of government relations for the association.

Thomas, the e-cigarette user, said she's been made to go outdoors with regular cigarette smokers at some places, such as a bingo hall, to vape and thinks that's "a crying shame."

"The very thing you're trying to get away from, which is smoking, they send you outside to be with the smokers," she said. "... It's vapor; it's not smoke."

But some research has found "formaldehyde, benzene and tobacco-specific nitrosamines (a carcinogen) coming from those secondhand emissions," according to the American Lung Association.

A 2014 report by the World Health Organization also notes that the aerosol from e-cigarettes is not just water vapor. Using e-cigarettes, which the WHO calls electronic nicotine delivery systems, "increases exposure of non-smokers and bystanders to nicotine and a number of toxicants," the report notes. However, "it is unknown if the increased exposure to toxicants and particles in exhaled aerosol will lead to an increased risk of disease and death among bystanders as does the exposure to tobacco smoke."

The WHO report also notes that using well-regulated e-cigarettes as a complete substitute for cigarettes "is likely to be less toxic for the (adult) smoker than conventional cigarettes or other combusted tobacco products."

The Royal College of Physicians in London published a commentary in March by three academics from the UK Centre for Tobacco and Alcohol Studies in the United Kingdom that said "e-cigarette emissions are much less hazardous than tobacco smoke." It also said that "for the smoker who cannot quit, or wants to continue to use nicotine in a manner that resembles smoking, e-cigarettes are an obvious choice. Switching completely from tobacco to e-cigarettes achieves much the same in health terms as does quitting smoking and all nicotine use completely."

The WHO report notes that use of e-cigarettes is likely to help some people quit smoking for good but that many will use it to reduce cigarette use rather than quitting altogether. It also notes that the evidence for using e-cigarettes as a method of quitting is limited.

More conventional tools to stop smoking include nicotine-replacement products, such as patches and gum; counseling; and medications, such as Chantix.

If smokers have tried all such options without success, e-cigarettes "would be a conversation for them to have with their physician, but so far, not enough studies have been done to prove they're an effective cessation product," Chang said.

The FDA announced last April that it had proposed a new rule to extend its authority over nicotine-containing e-cigarettes and some other products, such as cigars, pipe tobacco, nicotine gels and waterpipe (or hookah) tobacco. It's unclear when the FDA will issue a final rule. But the proposed rule calls for things like submitting product and ingredient listings; adhering to minimum age and identification restrictions; including a warning label; only marketing new products after FDA review; and not making claims, such as "light" or "mild," without FDA authorization and scientific proof.

Mayfield Gibson said people who choose to use e-cigarettes need to know that "nicotine itself is a highly addictive drug, and we know that nicotine can have adverse effects during pregnancy and can contribute to cardiovascular disease, and more recently, it's being studied even as a promoter of tumors." She said it also can have "adverse effects" on the adolescent brain.

Lesser of two evils

In the 2014 Monitoring the Future Study — a survey of 40,000 to 50,000 students — 9 percent of eighth-graders reported using an e-cigarette in the past 30 days, but only 4 percent reported using a regular cigarette. Among 12th-graders, 17 percent had used an e-cigarette, compared to 14 percent reporting use of regular cigarettes.

Nesbitt said the e-cigarette industry is clearly targeting kids by flavoring the products and offering styles that appeal to teens.

But LeBlanc explained the reasoning for the flavoring this way: "Once you quit smoking you figure out that cigarettes taste like crap," he said. "We always encourage people to start with the tobacco flavor and then within two to three weeks, 80 percent of them ... end up going to something more flavorful."

LeBlanc said Derb E Cigs is helping many people to quit by putting them on a plan that allows them to consume dwindling amounts of nicotine, or even no nicotine at all. "Nicotine in any form is not safe," he acknowledged. But he maintains that e-cigarettes are "absolutely" safer than regular cigarettes.

Thomas credits e-cigarettes with making it possible for her to stop smoking a pack and a half a day of regular cigarettes. She started off vaping a heavy dose of nicotine, then scaled down to almost no nicotine, she said.

Now, the e-cigarettes are "like a security blanket, but I really could get rid of it altogether," she said. "I just like the flavor of this stuff."

Martin Bos, 40, of the Highlands has been using e-cigarettes for two years. He credits vaping with helping him to stop using regular cigarettes and likes that he's not generating secondhand smoke from traditional cigarettes. He also has gotten into the hobby aspects of e-cigarettes, such as collecting and tinkering with them.

He said it's probably a good idea for the industry to be more regulated to foster more research and to regulate the "juice" as the marketplace grows. But he sees e-cigarettes as the lesser of two evils when compared to traditional cigarettes.

Former pack-a-day smoker Michael Park, a fellow Derb E Cigs customer, said he likes e-cigarettes because they smell and taste better than regular cigarettes. "Food tastes a lot better, too."

Park, 23, knows e-cigarettes are controversial, but "I don't reek (of) cigarette smoke. I breathe better. I think I sleep better and have got more energy, too."