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Are Electronic Cigarettes A Public Good Or A Health Hazard?

BY MICHAEL BLANDING, Forbes

When electronic cigarettes first appeared a little over a decade ago, they were hailed by public health advocates-as well as some smokers-as a godsend: a tool to help smokers quit while mitigating the most harmful effects of tobacco. “The [e-cigarette] market is producing, at no cost to the taxpayer, an emerging triumph of public health,” one health advocate said.

Consisting of a small barrel-shaped design that mimics an actual cigarette, the devices vaporize a liquid nicotine solution, which is then inhaled without the tar and carcinogens found in smoke. Powered by a battery and controlled with a microchip, users can adjust the amount of nicotine they inhale, gradually weaning themselves off of their addiction if they choose.
“The value proposition of e-cigarettes is clear,” saysJohn A. Quelch, Charles Edward Wilson Professor of Business Administration at Harvard Business School. “They provide the dubious pleasure of nicotine without all the cancer-inducing toxins associated with tobacco.”
Very quickly, however, enthusiasm faded, when some public health advocates began worrying that the cure was worse than the disease.
The very fact users could control the amount of nicotine they ingested led to worry that e-cigarettes would cause smokers to take in more nicotine, rather than less. Even more worrisome, “eCigs” could provide a gateway for young people to start smoking tobacco cigarettes, or even lure ex-smokers back to the habit.

Electronic Cigarette Smoking(Photo credit: planetc1) 

This has created a dilemma for health regulators, says Quelch. Do they regulate e-cigarettes in order to decrease the number of new smokers who may pick up the habit, or do they apply a light hand in order to increase the number of existing smokers who will quit.
“Put crudely,” says Quelch, “how many nicotine addicts is it worth the risk of creating to have one tobacco smoker quit?”

That is one of the many dilemmas Quelch explores in the HBS case, E-Cigarettes: Marketing Versus Public Health, written with HBS Research Associate Margaret L. Rodriguez. It examines the consequences of the products as they have become more popular — and as the big tobacco companies have gotten in on the game. Quelch, who holds a joint appointment at HBS and Harvard School of Public Health, wrote the case for a new course debuting next year called “Consumers, Corporations, and Public Health,” which will enroll both MBA and MPH students to consider the intersections of business and health.
“One of the themes in the course is the tension that exists, quite understandably, between regulators and commercial interests,” says Quelch. “Most people are used to hearing about that in the context of financial regulation, but similar issues apply in other sectors of the economy including health care.”
In the case of electronic cigarettes, existing evidence indicates that they have led to a net decrease in smoking. Of the 43.8 million smokers in the United States in 2012, 3.5 million converted to eCigs; during the same period only 1.3 million eCig smokers converted to tobacco. That means a net decrease of cigarette smokers of 2.2 million, or 5%.
At the same time, 2.8 million nonsmokers converted to electronic smokes. But even that doesn’t tell the whole story, says Quelch, since it leaves out the number of smokers who would have taken up smoking tobacco if e-cigarettes didn’t exist, as well as the number of smokers who would have quit cold turkey without the availability of electronic products. “To really determine the public health impact of e-cigarettes requires a lot of sophisticated market research and analysis,” says Quelch.
A Smoking Market

Uncertainty over health data hasn’t hurt the product’s popularity. In 2013, electronic cigarettes tripled in sales in the U.S. to approximately $3 billion. (The overall tobacco retail market in the US is valued at around $100 billion.) Almost 10% of high school students have tried them, according to the Centers for Disease Control, and a growing percentage of middle school students are joining the parade. In 2012, Goldman Sachs declared electronic cigarettes one of the top 10 disruptive technologies to watch.
Like most disruptive technologies, electronic cigarettes were developed by small entrepreneurs with brand names like Logic eCig (founded 2010), Blu (2009) and NJOY (2006). By 2013, according to the case study, the e-cigarette category featured more than 200 brands and their growth was threatening sales of tobacco cigarettes.
“If I am a tobacco manufacturer seeing my sales cannibalized by e-cigarettes, I have two choices: develop my own e-cigarette brand or buy an e-cigarette company,” says Quelch.
Number three tobacco company Lorillard LO -2.47%was the first to blink, buying up Blu in 2012 for $135 million and aggressively pushing them at convenience store counters. “Distribution of Blu immediately increased by a factor of three,” says Quelch. Other top manufacturers Phillip Morris and Altria followed suit, acquiring their own brands and using their shelf-space clout to increase visibility of the alternative products.
The growing sales of electronic cigarettes also caught the attention of regulators. The products had been completely unregulated–they could be advertised on TV and sold to buyers of any age on the Internet. But once the major tobacco brands began acquiring e-cigarette makers and displaying those products alongside their mainstay cigarettes, regulators took particular notice.
Public health advocates and parents alike worried about the variety of flavors, including cotton candy, that might make “vapes” attractive to children. Some states and cities responded with restrictions on sales and advertising, and, in April, the Financial Times reported that the World Health Organization will call for e-cigarettes to be regulated just like tobacco cigarettes. The US Food and Drug Administration, under mounting pressure to act, plans to offer marketing and product regulations for electronic cigarettes in the near future.
Ironically, if regulation does go forward, it might help the major tobacco companies, by limiting the marketing playbook of the competitors that were cannibalizing sales of their products.
“Altria or Phillip Morris know how to deal with regulators,” says Quelch, “but with all those entrepreneurs coming out with flavors and advertising, they would no longer be able to get traction in their business.”

Tobacco Companies Take Control 
Quelch predicts the big three tobacco companies will gain control of the eCigs market and then undermarket their electronic products in order to retain market share for their more profitable tobacco cigarettes. “Cigarette companies will manage the marketing of e-cigarette brands to maximize profitability for their shareholders,” says Quelch. “Meaning they’ll be able to manipulate prices in order to control the speed with which tobacco users migrate to e-cigarette brands.”
That means that electronic cigarettes, which are now significantly cheaper on a smoke-per-smoke basis than heavily taxed tobacco competitors, will probably start climbing in price and eventually become equal to tobacco brands. That could create an even bigger windfall for Phillip Morris, Altria, and Lorillard. Even if eCigs are regulated like regular cigarettes, they probably won’t be taxed like regular cigarettes, since the tax is on tobacco, not nicotine (and doesn’t apply, for example, to nicotine gum or nicotine patches)-and any new taxes are a nonstarter these days in Congress.
By pricing electronic and tobacco cigarettes to sell similarly at retail, the tobacco companies could reap enormous profits, concludes Quelch-at the same time giving them cover against criticism by allowing them to point to “healthier alternatives” in their product portfolios.
When entrepreneurs first created e-cigarettes and marketed them as a way to quit smoking, they probably didn’t intend to eventually pad the bottom line of mainstream big tobacco companies. But playing out the scenario to the end, that is exactly what may happen-and all in the absence of any definitive data showing whether e-cigarettes are more or less harmful to public health than tobacco smokes.
By pointing out such dichotomies and unintended consequences, Quelch hopes he can motivate MBA students to think more deeply about the public health impacts of business decisions-as well as getting MPH students to think about the business forces that shape public health. Only then will decisions be made that properly balance the greatest good of the public with the ability for entrepreneurs to turn a profit.

E-Cigarette Poisoning on the Rise, CDC Says

By Neha Sharma, DO, ABC News
They’re supposedly a safer alternative to conventional cigarettes. But electronic cigarettes may actually pose a serious danger to others in your home — particularly children.
The U.S. Centers for Disease Control and Prevention warned in report released today that the number of phone calls to U.S. poison control centers related to e-cigarette use has increased from just one call per month on average in 2010 to nearly 200 calls per month in early 2014.
“The rise in the numbers of e-cigs related calls to poison centers leads us to view this as a major public health concern,” said report author Dr. Kevin Chatham-Stephen, a pediatrician and an epidemiologist with the CDC.
He said that though e-cigs comprise less than 2 percent of all tobacco-related sales, they now account for more than 40 percent of poison center calls. More than half of the calls involved children younger than 5 years old.
“This is a very dramatic finding,” Chatham-Stephen said.
According to the report, most of these emergencies are linked to the liquid nicotine within the e-cigs. If the liquid is released from the cylinder that holds it, the result can be acute nicotine toxicity from direct skin or eye exposure, ingestion, or inhalation.
“Cigarettes are the most dangerous consumer product on the planet, and smokers need to treat e-cigs with considerable caution especially since the product is unregulated.” said Dr. Tim MacAfee, director of the Office on Smoking and Health at CDC and contributor to the report.
Those within the e-cigarette industry said concerns are overblown. Jason Healy, the president of e-cigarette manufacturer Blu-cigs, called the findings in the report “a weak argument” against the devices and is evidence of “an ongoing attack on the e-cigs industry by various anti-smoking groups.”
“The product is for adult smokers, and therefore the responsibility for children’s safety falls on the parents, just like bleaches and prescription medications,” Healy said. “The focus should be on parenting and education, and not regulation.”
Healy did say, however, that the findings should prompt the e-cig industry to formulate effective child safety measures.
Still, toxicology experts not involved in the study said the report reveals a concerning threat to kids.
“Nicotine is probably the most toxic plant chemical ever discovered,” said Dr. Richard Clark, medical director for the California Poison Control System and a professor of toxicology. Clark said poison centers like his are seeing a steady increase in calls related to e-cigs. Of particular concern, he said, is that unlike the conventional cigarette, which is usually very bitter, these devices are flavored and thus more attractive to children. The solution is also easily absorbed through the skin if spilled, unlike the contents of regular cigarettes.
Doctor’s Take
Despite decades of admonitions against smoking, an estimated 42 million people in the United States still smoke cigarettes. Cigarette smoking is the leading cause of preventable death in the United States, accounting for one of every five deaths each year. So for many, the electronic option may hold a certain appeal.
But though e-cigarette use is increasing among U.S. adolescents and adults, its overall impact on public health remains unclear. The dramatic rise in E-cigarette related calls to the country’s poison control centers is alarming. And the fact that the product is not childproof should alert parents to keep the product out of reach and in an enclosed container.
http://abcnews.go.com/blogs/health/2014/04/03/e-cigarette-poisoning-is-on-the-rise-cdc-says/

Study Looking To See If E-Cigs Curb Smoking Habits

WCCO, CBS Minnesota
MINNEAPOLIS (WCCO) – A new study is looking into whether or not electronic cigarettes are an effective way to stop, or cut back on smoking as many smokers turn to them as an alternative.
E-cigarettes turn a liquid solution into a vapor, and some contain nicotine.
Researchers at the University of California, San Francisco followed nearly 1,000 smokers for a year. During which time they found no link between e-cigarettes and quitting, or cutting down on smoking.
“There was no association between having tried an e-cigarette and using an e-cigarette and quitting smoking at one year follow up,” Dr. Rachel Grana of the UCSF said.
The study also found that women are more likely to use e-cigarettes than men.
The Tobacco Vapor Electronic Cigarette Association is criticizing the study for its limited data.
http://minnesota.cbslocal.com/2014/03/24/study-looking-to-see-if-e-cigs-curb-smoking-habits/

ERIC JOHNSON: E-cigs’ risks are real while benefits are scant

By Eric Johnson, Op-Ed, Grand Forks Herald
GRAND FORKS — According to the Centers for Disease Control and the U.S. Surgeon General, tobacco kills about 480,000 persons every year in the United States.
In 1964, about 41 percent of adults were cigarette smokers. Today, that rate is down to a little more than 18 percent. Significant strides have been made over the past five decades to reduce smoking and the tremendous health and financial burden it puts on our society.
In North Dakota alone, tobacco use still contributes to about $250 million in health care expenditures.
Encouraging people to quit tobacco remains a high priority with regard to the health of Americans, yet only two states in the nation — Alaska and North Dakota — fund anti-tobacco programs at levels recommended by the CDC.
In North Dakota, our efforts continue to be supported by the public. Public sentiment, expressed at the ballot box and in polling, shows that reducing tobacco use remains a high priority for North Dakotans. In 2008, voters approved Measure 3 to support funding of anti-tobacco programs; and in 2012, the statewide smoke-free law — passed as a ballot measure — got 67 percent of the vote, winning support from a majority of voters in every legislative district.
Some 89 percent of North Dakotans polled in 2013 think the funds designated for tobacco control should stay there.
What works to help people quit tobacco? The U.S. Preventive Task Force and the Surgeon General endorse medications that have proven effectiveness with a known, Food and Drug Administration-approved, safety and side-effect profile.
These include nicotine replacement products such as gum, patches or lozenges, as well as prescription medications such as Chantix (Varenicline) or Wellbutrin (Buproprion).
Proven counseling programs, such as NDQuits (available free to all North Dakotans who use tobacco), also are very effective, particularly when combined with an FDA-approved medication.
Electronic cigarettes (e-cigs) are increasingly popular products that fall into the unproven category. First invented in the 1960s, their popularity has continued to increase as large tobacco companies buy small “mom-and-pop” manufacturers. With more than 250 brands on the market, (“Blu,” “NJOY” and “Vuse” popular in America), e-cigs are battery-powered (some disposable, some rechargeable) with a vaporizer and mouthpiece attached.
When used, commonly referred to as “vaping,” the vaporizer boils the liquid inside, which most frequently contains three major ingredients — humectants (propylene glycol/glycerin, used in fog and smoke machines and antifreeze), nicotine (at varying levels) and flavoring (fruit flavors, bubble gum, cotton candy, bacon and coffee, to name a few).
Unlike other medications that are used to promote quitting tobacco, e-cigs are largely unregulated by the Food and Drug Administration; and to date, we have no real data to show that they are effective as a cessation product nor any data to show that they are safe.
Furthermore, some of these manufacturers have been cited for contaminants in their products, including nickel, arsenic and chromium.
Without FDA oversight, these products aren’t taxed, they can be sold to anyone of any age, and there are no restrictions on advertising, which is why we see and hear ads on TV, in magazines and on the radio.
Though the industry denies it, it’s apparent that these products are being marketed to children (unless we’re supposed to believe that “Hello Kitty” e-cigs are popular among adult users).
E-cig manufacturers, rather than relying on science, really are trying to “normalize” smoking again for the next generation. The recent national Youth Tobacco Survey showed a spike in use of e-cigs by youth, doubling to more than 10 percent in just one year.
In addition, many who use e-cigs become dual users, continuing to use other tobacco products at the same time.
Last but not least, the industry is playing on the desperate idea that anything else would be better than smoking traditional cigarettes. If that’s true, ask yourself why these same companies are so resistant to producing the data to back up their claims.
It’s disappointing that e-cigs have been marketed for more than 35 years and have yet to collect or publish any significant data to show they are safe for users or that they actually help people quit.
Considering these products increasingly are manufactured and marketed by Big Tobacco, I’m not anticipating we’ll see such data any time soon.
The FDA has made it very clear that e-cigs cannot be marketed as smoking cessation products as a result.
As a health care provider, I would love a good, new and novel option to help people quit smoking. Like other conditions I treat as a physician, I want to provide the best possible treatment for my patients, and that means practicing strategies and using medications that have scientific proof that they work and have an established safety profile.
To date, when it comes to quitting tobacco, that answer is not found in electronic cigarettes.
Dr. Johnson is a family physician at Altru Health System in Grand Forks.
http://www.grandforksherald.com/content/eric-johnson-e-cigs-risks-are-real-while-benefits-are-scant

Selling a Poison by the Barrel: Liquid Nicotine for E-Cigarettes

By , New York Times

A dangerous new form of a powerful stimulant is hitting markets nationwide, for sale by the vial, the gallon and even the barrel.

The drug is nicotine, in its potent, liquid form — extracted from tobacco and tinctured with a cocktail of flavorings, colorings and assorted chemicals to feed the fast-growing electronic cigarette industry.

These “e-liquids,” the key ingredients in e-cigarettes, are powerful neurotoxins. Tiny amounts, whether ingested or absorbed through the skin, can cause vomiting and seizures and even be lethal. A teaspoon of even highly diluted e-liquid can kill a small child.

But, like e-cigarettes, e-liquids are not regulated by federal authorities. They are mixed on factory floors and in the back rooms of shops, and sold legally in stores and online in small bottles that are kept casually around the house for regular refilling of e-cigarettes.

Evidence of the potential dangers is already emerging. Toxicologists warn that e-liquids pose a significant risk to public health, particularly to children, who may be drawn to their bright colors and fragrant flavorings like cherry, chocolate and bubble gum.

Photo

The liquid stimulant used in e-cigarettes, when ingested or absorbed through the skin, can cause vomiting, seizures or death. CreditFrank Franklin II/Associated Press

“It’s not a matter of if a child will be seriously poisoned or killed,” said Lee Cantrell, director of the San Diego division of the California Poison Control System and a professor of pharmacy at the University of California, San Francisco. “It’s a matter of when.”

Reports of accidental poisonings, notably among children, are soaring. Since 2011, there appears to have been one death in the United States, a suicide by an adult who injected nicotine. But less serious cases have led to a surge in calls to poison control centers. Nationwide, the number of cases linked to e-liquids jumped to 1,351 in 2013, a 300 percent increase from 2012, and the number is on pace to double this year, according to information from the National Poison Data System. Of the cases in 2013, 365 were referred to hospitals, triple the previous year’s number.

Examples come from across the country. Last month, a 2-year-old girl in Oklahoma City drank a small bottle of a parent’s nicotine liquid, started vomiting and was rushed to an emergency room.

That case and age group is considered typical. Of the 74 e-cigarette and nicotine poisoning cases called into Minnesota poison control in 2013, 29 involved children age 2 and under. In Oklahoma, all but two of the 25 cases in the first two months of this year involved children age 4 and under.

In terms of the immediate poison risk, e-liquids are far more dangerous than tobacco, because the liquid is absorbed more quickly, even in diluted concentrations.

“This is one of the most potent naturally occurring toxins we have,” Mr. Cantrell said of nicotine. But e-liquids are now available almost everywhere. “It is sold all over the place. It is ubiquitous in society.”

The surge in poisonings reflects not only the growth of e-cigarettes but also a shift in technology. Initially, many e-cigarettes were disposable devices that looked like conventional cigarettes. Increasingly, however, they are larger, reusable gadgets that can be refilled with liquid, generally a combination of nicotine, flavorings and solvents. In Kentucky, where about 40 percent of cases involved adults, one woman was admitted to the hospital with cardiac problems after her e-cigarette broke in her bed, spilling the e-liquid, which was then absorbed through her skin.

The problems with adults, like those with children, owe to carelessness and lack of understanding of the risks. In the cases of exposure in children, “a lot of parents didn’t realize it was toxic until the kid started vomiting,” said Ashley Webb, director of the Kentucky Regional Poison Control Center at Kosair Children’s Hospital.

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Nicotine solutions at Volt Vapes in Boise, Idaho. The “e-liquid” comes in colors and flavors that experts say may entice children. CreditKatherine Jones/The Idaho Statesman, via Associated Press

The increased use of liquid nicotine has, in effect, created a new kind of recreational drug category, and a controversial one. For advocates of e-cigarettes, liquid nicotine represents the fuel of a technology that might prompt people to quit smoking, and there is anecdotal evidence that is happening. But there are no long-term studies about whether e-cigarettes will be better than nicotine gum or patches at helping people quit. Nor are there studies about the long-term effects of inhaling vaporized nicotine.

 Unlike nicotine gums and patches, e-cigarettes and their ingredients are not regulated. The Food and Drug Administration has said it plans to regulate e-cigarettes but has not disclosed how it will approach the issue. Many e-cigarette companies hope there will be limited regulation.

“It’s the wild, wild west right now,” said Chip Paul, chief executive officer of Palm Beach Vapors, a company based in Tulsa, Okla., that operates 13 e-cigarette franchises nationwide and plans to open 50 more this year. “Everybody fears F.D.A. regulation, but honestly, we kind of welcome some kind of rules and regulations around this liquid.”

Mr. Paul estimated that this year in the United States there will be sales of one million to two million liters of liquid used to refill e-cigarettes, and it is widely available on the Internet. Liquid Nicotine Wholesalers, based in Peoria, Ariz., charges $110 for a liter with 10 percent nicotine concentration. The company says on its website that it also offers a 55 gallon size. Vaporworld.biz sells a gallon at 10 percent concentrations for $195.

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The website of Liquid Nicotine Wholesalers. The Food and Drug Administration has yet to impose rules on e-liquids’ sale.

Mr. Paul said he was worried that some manufacturers outside the United States — China is a major center of e-cigarette production — were not always delivering the concentrations and purity of nicotine they promise. Some retailers, Mr. Paul said, “are selling liquid and they don’t have a clue what is in it.”

 Cynthia Cabrera, executive director of Smoke Free Alternatives Trade Association, said she would also favor regulations, including those that would include childproof bottles and warning labels, and also manufacturing standards. But she said many companies already were doing that voluntarily, and that parents also needed to take some responsibility.

“You wouldn’t leave a bottle of Ajax out,” she said. Advocates of e-cigarettes sometimes draw comparisons between nicotine and caffeine, characterizing both as recreational stimulants that carry few risks. But that argument is not established by science, and many health advocates take issue with the comparison.

“There’s no risk to a barista no matter how much caffeine they spill on themselves,” said Dr. Neal L. Benowitz, a professor at the University of California, San Francisco, who specializes in nicotine research. “Nicotine is different.”

Without proper precautions, like wearing gloves while mixing e-liquids, these products “represents a serious workplace hazard,” he said.

The nicotine levels in e-liquids varies. Most range between 1.8 percent and 2.4 percent, concentrations that can cause sickness, but rarely death, in children. But higher concentrations, like 10 percent or even 7.2 percent, are widely available on the Internet. A lethal dose at such levels would take “less than a tablespoon,” according to Dr. Cantrell, from the poison control system in California. “Not just a kid. One tablespoon could kill an adult,” he said.

http://www.nytimes.com/2014/03/24/business/selling-a-poison-by-the-barrel-liquid-nicotine-for-e-cigarettes.html?_r=0

Youth poisonings by e-cigarette juice increase tenfold in Minnesota

By: John Lundy, Forum News Service, INFORUM
DULUTH – The tenfold increase in Minnesota youngsters poisoned by e-cigarette juice last year is alarming, a local anti-smoking advocate said.
“It’s a startling increase and something we should be very concerned about,” said Pat McKone, Duluth-based director of tobacco control programs and policy for the American Lung Association of the Upper Midwest.
But it needs to be viewed in context, said Duluth e-cigarette proprietor Daniel Albrecht, citing a much greater number of poisonings from other products.
The Minnesota Department of Health reported Tuesday that 50 teens and children were victims of poisonings related to e-cigs in 2013, compared with five the year before. More than half of those poisoned were younger than 3, and nine of the 50 were teenagers. Another 24 adults were poisoned, a news release said.
The data came from the Minnesota Poison Control System.
More than 200 Minnesota retailers sell the product, which is an electronic device that vaporizes water to supply liquids. The liquids used in e-cigarettes often include flavors such as cotton candy, bubble gum and grape. They may or may not contain nicotine.
Most e-cigarette shops opened in the past year, including two in Duluth.
Albrecht owns one of those, E-cig Empire, with his brother Mike. Most of the e-juice sold is with child-resistant caps, Albrecht said, and what he calls the vaping community is pushing for all of it to be child-safe.
“Everyone in the vaping community is all for keeping it out of the hands of children and minors,” Albrecht said. “And we’re all for that sort of legislation.”
But other products take a greater toll, Albrecht said. Close to 3,200 calls were made to Minnesota Poison Control related to personal-care products last year, he said, and almost 2,400 calls were made regarding household products.
But Albrecht said he opposes eliminating any flavors and argued that those flavors aren’t offered to appeal to children.
“As adults, we all have a right to choose,” he said. “We all had to put up with smoking the traditional analog cigarettes and they all tasted nasty and smelled gross, and now we have an alternative that we could have flavoring in it.”
Minnesota legislators are considering regulating e-cigarettes. Duluth, Cloquet and Hermantown are among Minnesota cities that already have adopted regulatory actions.
Four states — New Jersey, Utah, Arkansas and North Dakota — have passed legislation banning the use of e-cigarettes in public places.
McKone said the latest report goes hand in hand with a U.S. Centers for Disease Control and Prevention report last year that e-cigarette use had doubled among teenagers from 2011 to 2012.
None of last year’s poisonings resulted in hospitalizations or serious illness, state Health Commissioner Ed Ehlinger said.
But McKone said the fact that symptoms were alarming enough to cause calls to the Poison Control System speaks for itself.
“I hope we don’t have to have a fatality to say it wasn’t so bad,” McKone said. “I think as a parent myself any time I would be in a position to be calling Poison Control and concerned about my child having ingested something and having symptoms — that’s more than enough cause for us to be concerned.”
But responsible parenting can prevent those problems, Albrecht said.
“I think parents of children need to be much more responsible and keep things out of reach,” he said.
Symptoms of nicotine poisoning may include nausea, vomiting, diarrhea, seizures and/or difficulty breathing, the Health Department news release said. A fatal dose of nicotine for an adult is between 50 and 60 milligrams. E-juice containers may include between 18 and 24 milligrams.

Don Davis contributed to this report.
http://www.inforum.com/event/article/id/429747/

Teenage E-Cigarette Use Likely Gateway to Smoking

By Caroline Chen, Bloomberg News
E-cigarettes facing municipal bans and scrutiny by U.S. regulators received a new slap on the wrist from scientists: A report today suggests the devices may be a gateway to old-fashioned, cancer-causing smokes for teens.
Youths who reported ever using an e-cigarette had six times the odds of smoking a traditional cigarette than those who never tried the device, according to a study published today in the journal JAMA Pediatrics. E-cigarette use didn’t stop young smokers from partaking in regular cigarettes as well.
The global market for e-cigarettes may top $5 billion this year, according to Euromonitor International Ltd. estimates. Makers of the devices, including Altria Group Inc. (MO), the largest U.S. tobacco company, market them online and on TV, where traditional tobacco ads are banned, and some have added flavors such as bubble gum to the nicotine vapor that may have extra appeal for youths. That allure is why the U.S. Food and Drug Administration needs to restrict the devices, opponents say.
“The FDA needs to act now,” Vince Willmore, spokesman for the Washington-based Campaign for Tobacco-Free Kids, said in a telephone interview. “We think it’s overdue.”
Concerns about underage use of e-cigarettes were raised last year when the U.S. Centers for Disease Control and Prevention in Atlanta reported that use of the devices by youths doubled in 2012 from a year earlier.
“E-cigarettes are likely to be gateway devices for nicotine addiction among youth, opening up a whole new market for tobacco,” said Lauren Dutra, a post-doctoral fellow at the University of California at San Francisco and the report’s lead author. “We’re most worried about nicotine addiction initiation in youth.”

Enticing Product

E-cigarettes “are enticing for kids,” said Donovan Robinson, dean of students at Chicago’s Lincoln Park High School. He said today’s findings weren’t surprising. “They’ll say, ‘Hey, now let’s try the real thing.’”
Children in middle and high school, the target of the research, don’t think about health consequences, he said.
“Everything is a fad with teenagers,” Robinson said. They use e-cigarettes “because it looks cool. Teenagers see somebody doing something cool, and they want to do it.”
The latest research analyzed data from the 2011 and 2012 National Youth Tobacco Survey, conducted by the Centers for Disease Control and Prevention. Almost 40,000 middle and high school students from about 200 schools across the U.S. participated in the survey. Students were asked about their frequency of use of e-cigarettes, conventional cigarettes, cigars, pipes, and other tobacco products.

No Tar

While battery-powered e-cigarettes enable the ingestion of heated nicotine, users avoid the tars, arsenic and other chemicals common in tobacco products that have been linked to cancer, supporters have said.
The study today shows correlation, not causation, said Cynthia Cabrera, executive director of Smoke-Free Alternatives Trade Association, the Washington-based e-cigarette association.
“I’ve yet to see any science that shows there’s a gateway effect,” Cabrera said in a telephone interview. “We want to work with facts and science, we don’t want to make knee-jerk decisions based on emotional responses.”
Cabrera warned against drawing inferences on teen use based on the use of flavors in e-cigarettes.
“We do know that thousands of people were able to switch over to vapor products because of the flavors,” she said in a telephone interview. “Would we deny people who were in a group who could die from tobacco to use flavors that helped them get off killer tobacco?”

Nicotine Effects

Opponents have countered that nicotine alone is so toxic it’s been used in the past as a pesticide. They say the health effects of nicotine, which has proven to be habit forming, are unclear and deserve more study. Until that’s done, they’ve said, advertising of the devices should be closely monitored to make sure it isn’t aimed at underage smokers.
“We’re concerned that the marketing for e-cigarettes risks re-glamorizing smoking” among youths who won’t make the distinction between electronic and conventional cigarettes, Willmore said.
In December, a billboard in Miami used Santa Claus to market e-cigarettes and in the recent Sports Illustrated bathing suit issue there was an ad for one of the devices “right in the middle of a bikini bottom,” he said.
“You couldn’t design an ad more appealing to a teenage boy,” Willmore said.

Pivotal Year

This is expected to a pivotal year for producers of electronic cigarettes, with all major tobacco companies either launching new products or expanding their e-cigarette sales exposure, said Kenneth Shea, a Bloomberg analyst. Altria, Reynolds American Inc. and Lorillard Inc. are all expected to pursue U.S. exposure for their e-cigarettes, while closely held Logic Technology Development LLC and Sottera Inc., the maker of the e-cigarette NJoy, try to keep pace, Shea wrote in a report this month.
While tobacco companies have been under the FDA’s watchful eye since Congress gave the agency authority over the $90 billion industry in 2009, e-cigarettes haven’t been subject to the same oversight. The agency is now in the process of readying new rules for the industry designed to establish clear manufacturing standards and set boundaries for how the products can be marketed.
Federal regulators aren’t the only government officials moving to control use of e-cigarettes. On March 4, the Los Angeles City Council voted to join New York and Chicago in banning the use of the electronic products in in workplaces, restaurants and many public areas.

Bans Criticized

The municipal restrictions were criticized by Miguel Martin, president of Logic Technology, the second-largest independent e-cigarette maker in the U.S. Localities should wait for the FDA to make its views known before taking action, Martin said in an interview before the council vote.
“I find it odd that everybody looks to the FDA for guidance on everything else, but because it’s politically expedient, they don’t on this,” Martin said.
http://www.bloomberg.com/news/2014-03-06/teenage-e-cigarette-use-likely-gateway-to-smoking.html

Doctor Wants Lawmakers to Classify E-Cigarettes as Tobacco

By: WILX NEWS 10
Michigan’s top doctor is calling on state lawmakers to classify e-cigarettes as tobacco products. Legislation currently in the Senate would make it a crime to sell the devices to minors. But Dr. Matthew Davis, Chief Medical Executive with the Michigan Department of Community Health says the bi-partisan package of bills doesn’t go far enough.
E-cigarettes are electronic devices that heat up liquid and allow the user to inhale a vapor. Davis says, “What we’re seeing is that kids are trying these in higher and higher numbers and many parents are concerned. We know this from national research, that their kids may get addicted to nicotine and end up using traditional cigarettes down the road.” Republican Senator Rick Jones of Grand Ledge agrees. “We have a problem in this state. Any 10 year-old can go in and buy electronic cigarettes. Some are flavored like root beer, orange, even cheesecake. and children are getting addicted to nicotine.”
Jones has sponsored Senate Bills 667 & 668. The legislation would make it immediately illegal for retailers to sell e-cigarettes to minors. But Davis says, that isn’t good enough. He wants lawmakers to protect everyone from the dangers of e-cigarettes by taxing them, and banning them from restaurants, bars and other public places. Davis says, “After all, liquid in e-cigarettes is extracted from tobacco and so therefore, they are essentially tobacco products . And certainly tobacco-derived products, it would make sense to use the existing regulations that we have about tobacco products and classify e-cigarettes under that existing regulation.” Jones says, he’s more concerned about limiting access to children. “I understand that they want the moon, and they want to be able to tax these devices just like cigarettes but that will have to wait for an FDA decision. Anything the federal government does will override Michigan law so there is no problem.”
While retailers can sell e-cigarettes to anyone, many say they treat them just like cigarettes and don’t sell to minors. Many restaurants also ban the devices. The legislation is now in a Senate committee.
http://www.wilx.com/home/headlines/Doctor-Wants-Lawmakers-to-Classify-E-Cigarettes-as-Tobacco-248439351.html?ref=351

A Hot Debate Over E-Cigarettes as a Path to Tobacco, or From It

By , The New York Times

Dr. Michael Siegel, a hard-charging public health researcher at Boston University, argues that e-cigarettes could be the beginning of the end of smoking in America. He sees them as a disruptive innovation that could make cigarettes obsolete, like the computer did to the typewriter.

But his former teacher and mentor, Stanton A. Glantz, a professor of medicine at the University of California, San Francisco, is convinced that e-cigarettes may erase the hard-won progress achieved over the last half-century in reducing smoking. He predicts that the modern gadgetry will be a glittering gateway to the deadly, old-fashioned habit for children, and that adult smokers will stay hooked longer now that they can get a nicotine fix at their desks.

These experts represent the two camps now at war over the public health implications of e-cigarettes. The devices, intended to feed nicotine addiction without the toxic tar of conventional cigarettes, have divided a normally sedate public health community that had long been united in the fight against smoking and Big Tobacco.

The essence of their disagreement comes down to a simple question: Will e-cigarettes cause more or fewer people to smoke? The answer matters. Cigarette smoking is still the single largest cause of preventable death in the United States, killing about 480,000 people a year.

Dr. Siegel, whose graduate school manuscripts Dr. Glantz used to read, says e-cigarette pessimists are stuck on the idea that anything that looks like smoking is bad. “They are so blinded by this ideology that they are not able to see e-cigarettes objectively,” he said. Dr. Glantz disagrees. “E-cigarettes seem like a good idea,” he said, “but they aren’t.”

Science that might resolve questions about e-cigarettes is still developing, and many experts agree that the evidence so far is too skimpy to draw definitive conclusions about the long-term effects of the devices on the broader population.

“The popularity is outpacing the knowledge,” said Dr. Michael B. Steinberg, associate professor of medicine at the Robert Wood Johnson Medical School at Rutgers University. “We’ll have a better idea in another year or two of how safe these products are, but the question is, will the horse be out of the barn by then?”

This high-stakes debate over what e-cigarettes mean for the nation’s 42 million smokers comes at a crucial moment. Soon, the Food and Drug Administration is expected to issue regulations that would give the agency control over the devices, which have had explosive growth virtually free of any federal oversight. (Some cities, like Boston and New York, and states, like New Jersey and Utah, have already weighed in, enacting bans in public places.)

The new federal rules will have broad implications for public health. If they are too tough, experts say, they risk snuffing out small e-cigarette companies in favor of Big Tobacco, which has recently entered the e-cigarette business. If they are too lax, sloppy manufacturing could lead to devices that do not work properly or even harm people.

And many scientists say e-cigarettes will be truly effective in reducing the death toll from smoking only with the right kind of federal regulation — for example, rules that make ordinary cigarettes more expensive than e-cigarettes, or that reduce the amount of nicotine in ordinary cigarettes so smokers turn to e-cigarettes for their nicotine.

“E-cigarettes are not a miracle cure,” said David B. Abrams, executive director of the Schroeder National Institute for Tobacco Research and Policy Studies at the Legacy Foundation, an antismoking research group. “They need a little help to eclipse cigarettes, which are still the most satisfying and deadly product ever made.”

Smoking is already undergoing a rapid evolution. Nicotine, the powerful stimulant that makes traditional cigarettes addictive, is the crucial ingredient in e-cigarettes, whose current incarnation was developed by a Chinese pharmacist whose father died of lung cancer. With e-cigarettes, nicotine is inhaled through a liquid that is heated into vapor. New research suggests that e-cigarettes deliver nicotine faster than gum or lozenges, two therapies that have never quite taken off.

Sales of e-cigarettes more than doubled last year from 2012, to $1.7 billion, according to Bonnie Herzog, an analyst at Wells Fargo Securities. Ms. Herzog said that in the next decade, consumption of e-cigarettes could outstrip that of conventional cigarettes. The number of stores that sell them has quadrupled in just the last year, according to the Smoke Free Alternatives Trade Association, an e-cigarette industry trade group.

“E-cigarette users sure seem to be speaking with their pocketbooks,” said Mitchell Zeller, director of the F.D.A.’s Center for Tobacco Products.

Public health experts like to say that people smoke for the nicotine but die from the tar. And the reason e-cigarettes have caused such a stir is that they take the deadly tar out of the equation while offering the nicotine fix and the sensation of smoking. For all that is unknown about the new devices — they have been on the American market for only seven years — most researchers agree that puffing on one is far less harmful than smoking a traditional cigarette.

But then their views diverge.

Pessimists like Dr. Glantz say that while e-cigarettes might be good in theory, they are bad in practice. The vast majority of people who smoke them now also smoke conventional cigarettes, he said, and there is little evidence that much switching is happening. E-cigarettes may even prolong the habit, he said, by offering a dose of nicotine at times when getting one from a traditional cigarette is inconvenient or illegal.

What is more, critics say, they make smoking look alluring again, with images on billboards and television ads for the first time in decades. Dr. Glantz says that only about half the people alive today have ever seen a broadcast ad for cigarettes. “I feel like I’ve gotten into a time machine and gone back to the 1980s,” he said.

Researchers also worry that e-cigarettes could be a gateway to traditional cigarettes for young people. The devices are sold on the Internet. The liquids that make their vapor come in flavors like mango and watermelon. Celebrities smoke them: Julia Louis-Dreyfus and Leonardo DiCaprio puffed on them at the Golden Globe Awards.

A survey from the Centers for Disease Control and Prevention found that in 2012, about 10 percent of high school students said they had tried an e-cigarette, up from 5 percent in 2011. But 7 percent of those who had tried e-cigarettes said they had never smoked a traditional cigarette, prompting concern that e-cigarettes were, in fact, becoming a gateway.

“I think the precautionary principle — better safe than sorry — rules here,” said Dr. Thomas Frieden, director of the C.D.C.

E-cigarette skeptics have also raised concerns about nicotine addiction. But many researchers say that the nicotine by itself is not a serious health hazard. Nicotine-replacement therapies like lozenges and patches have been used for years. Some even argue that nicotine is a lot like caffeine: an addictive substance that stimulates the mind.

“Nicotine may have some adverse health effects, but they are relatively minor,” said Dr. Neal L. Benowitz, a professor of medicine at the University of California, San Francisco, who has spent his career studying the pharmacology of nicotine.

Another ingredient, propylene glycol, the vapor that e-cigarettes emit — whose main alternative use is as fake smoke on concert and theater stages — is a lung irritant, and the effects of inhaling it over time are a concern, Dr. Benowitz said.

But Dr. Siegel and others contend that some public health experts, after a single-minded battle against smoking that has run for decades, are too inflexible about e-cigarettes. The strategy should be to reduce harm from conventional cigarettes, and e-cigarettes offer a way to do that, he said, much in the way that giving clean needles to intravenous drug users reduces their odds of getting infected with the virus that causes AIDS.

Solid evidence about e-cigarettes is limited. A clinical trial in New Zealand, which many researchers regard as the most reliable study to date, found that after six months about 7 percent of people given e-cigarettes had quit smoking, a slightly better rate than those with patches.

“The findings were intriguing but nothing to write home about yet,” said Thomas J. Glynn, a researcher at the American Cancer Society.

In Britain, where the regulatory process is more developed than in the United States, researchers say that smoking trends are heading in the right direction.

“Motivation to quit is up, success of quit attempts are up, and prevalence is coming down faster than it has for the last six or seven years,” said Robert West, director of tobacco studies at University College London. It is impossible to know whether e-cigarettes drove the changes, he said, but “we can certainly say they are not undermining quitting.”

The scientific uncertainties have intensified the public health fight, with each side seizing on scraps of new data to bolster its position. One recent study in Germany on secondhand vapor from e-cigarettes prompted Dr. Glantz to write on his blog, “More evidence that e-cigs cause substantial air pollution.” Dr. Siegel highlighted the same study, concluding that it showed “no evidence of a significant public health hazard.”

That Big Tobacco is now selling e-cigarettes has contributed to skepticism among experts and advocates.

Cigarettes went into broad use in the 1920s — and by the 1940s, lung cancer rates had exploded. More Americans have died from smoking than in all the wars the United States has fought. Smoking rates have declined sharply since the 1960s, when about half of all men and a third of women smoked. But progress has slowed, with a smoking rate now of around 18 percent.

“Part of the furniture for us is that the tobacco industry is evil and everything they do has to be opposed,” said John Britton, a professor of epidemiology at the University of Nottingham in England, and the director for the U.K. Center for Tobacco and Alcohol Studies. “But one doesn’t want that to get in the way of public health.”

Carefully devised federal regulations might channel the marketing might of major tobacco companies into e-cigarettes, cannibalizing sales of traditional cigarettes, Dr. Abrams of the Schroeder Institute said. “We need a jujitsu move to take their own weight and use it against them,” he said.

Dr. Benowitz said he could see a situation under which the F.D.A. would gradually reduce the nicotine levels allowable in traditional cigarettes, pushing smokers to e-cigarettes.

“If we make it too hard for this experiment to continue, we’ve wasted an opportunity that could eventually save millions of lives,” Dr. Siegel said.

Dr. Glantz disagreed.

“I frankly think the fault line will be gone in another year,” he said. “The evidence will show their true colors.”

http://www.nytimes.com/2014/02/23/health/a-hot-debate-over-e-cigarettes-as-a-path-to-tobacco-or-from-it.html?_r=0

Officials hope to educate on e-cigarettes

By Matthew Liedke • Daily News
Advocates pushing for tobacco prevention are now having to deal with a new device on the market that isn’t subject to the same regulations as traditional cigarettes.
Jennifer Mauch, Richland County Tobacco Prevention coordinator, said a rising issue is e-cigarettes, and how traditional companies seem to be getting more and more involved.
“Altria, which produces Marlboro products, is among other large tobacco companies that are buying e-cigarette manufacturers,” Mauch said. “I’ve been looking back at the way traditional tobacco products were advertised and the advertising for e-cigarettes seems very much like a repeat.
“I think they are seeing that this is where the market is going, so they are buying it up,” said Mauch, who added that e-cigarettes make up 1 percent of national smoking sales.
The problem with these devices, Mauch explained, is the Food and Drug Administration doesn’t regulate e-cigarette products, as they don’t contain tobacco. This leads to not even knowing what is in the e-cigarette.
“They may be in fact safer than traditional cigarettes, but we just don’t know,” Mauch said. “The issue is that we don’t know how much nicotine is in them, or what else is in them. There are some who say they don’t contain any nicotine, but we don’t know if that’s the case.”
The laws in the different states throughout the country also give challenges to regulating the e-cigarette product. In North Dakota, Mauch explained, there is no age restrictions on the products which she called “a major gateway.”
North Dakota was proactive in another law, though, which bans using e-cigarettes inside all places that traditional tobacco products are not allowed. However, in other states, such as Minnesota, it can still be used inside such places.
“The fear is that it’s becoming a social norm again,” Mauch said. “So it’s like moving backwards.
Currently, Mauch said the best thing she can do is educate the public about e-cigarettes.
“It always starts small,” Mauch said. “At this point we are just trying to educate people and have them realize that we don’t know if this is a safe product yet, so proceed with caution if you plan to use it. Unless they are studied further and regulated, we really want to get people to notice the education that is out there and be careful.”
In terms of her own office dealing with the situation, Mauch said she is currently working with communities and schools to get youth tobacco ordinances in place, which add e-cigarettes to the definitions of tobacco products.
http://www.wahpetondailynews.com/news/article_2055b402-9117-11e3-8f2b-001a4bcf887a.html