Where we stand now: E-cigarettes

By Sandee Lamotte CNN

used by more people as a nicotine alternative

Researchers worry not enough is known about the long term effects of e-cig vapor
Newest research shows adolescents using e-cigarettes more likely to start smoking
cigarettes
(CNN)New research from the prestigious medical journal BMJ finds teens who use
e-cigarettes are more than three times as likely to be smoking traditional cigarettes
a year later.

The 6 most scientifically valid methods to quit smoking

E-cigarettes work by heating a pure liquid called "e-juice" -- composed of
flavorings, propylene glycol, glycerin and often nicotine -- until it vaporizes. The
resulting vapor is much less offensive to many -- both smokers and non-smokers -and some studies have shown it helps smokers quit. In fact many e-cigarette users
don't call themselves smokers, preferring to use the term "vapers" instead.
But are e-cigarettes really an effective way to quit smoking? Does "vaping"
introduce health issues all its own, such as encouraging adolescents who would
otherwise never smoke to take a puff off the real thing? Science and public policy
have bounced back and forth for over a decade, as different studies produce
different -- and sometimes contradictory -- results. Let's take a look at this
controversy over the years:

2003 headline: Invention of e-cigarettes

The inventor of the electronic cigarette, Hon Lik, smoking his invention in Beiijng on
May 25, 2009.
Three pack-a-day smoker Hon Lik, a 52-year-old Beijing pharmacist, creates the
first successful electronic cigarette after his father, another heavy smoker, dies of
lung cancer. By 2007, e-cigarettes are marketed in Europe and the U.S. by the
manufacturer Ruyan as a way to safely stop smoking tobacco.
Hon is not the first person on record to have the idea for an electronic non-tobacco
option. Herbert A. Gilbertfiled for a patent back in 1963, in an era when tobacco
smoking was widely accepted and the health risks were less apparent.

2008 headline: WHO slams e-cigarette marketing

In September 2008, the World Health Organization announces marketers should
immediately remove any claims that e-cigs are a "safe and effective smoking
cessation aid" because there is "no scientific evidence to confirm the product's
safety and efficacy."
Soon after, a study funded by e-cigarette manufacturer Ruyan declares the product
to be 100 to 1000 times less dangerous than smoking tobacco, adding that when
using their device, nicotine is "apparently not absorbed from the lung, but from the
upper airways."

2010 headline: The battle heats up

In May, 2009, the Food and Drug Administration releases the results of a test of two
U.S. e-cig brands, NJOY and Smoking Everywhere, that finds "very low" amounts
of nicotine in cartridges labeled as nicotine free. Then in July, an FDA press
release discourages the use of e-cigarettes, saying they contain carcinogens and an
ingredient used in antifreeze, diethylene glycol.
Another concern of the FDA's: E-cigarettes are often marketed and sold to
youngsters who, intrigued by the many flavors such as chocolate, bubblegum and
mint, might easily adopt a smoking habit as a result of trying the devices.

Vape supporters counter that diethylene glycol was found at a very low, non-toxic
level of 1%, and that the carcinogens are at the same levels as other FDA-approved
nicotine cessation products, like patches and gum.
By the end of the year, Amazon and Paypal restrict the sale of e-cigs on their
websites.

2011 headline: Interest in vaping for smoking cessation is high

Science begins to ramp up studies on the topic. Several studies find interest in ecigarettes is high among the American public: Google searches for e-cigs are higher
in the U.S. than any other nation.
A questionnaire of 3500 e-cigarette users finds most vape because they think it is
less toxic and cheaper than tobacco, and will help them quit or cut down on
tobacco smoking. Most ex-smokers (79%) in the study are afraid they will relapse if
they stop using e-cigarettes. The study doesn't examine the safety of the product.
Another, much smaller email study of 216 e-cigarette users finds that 31% were
tobacco free at six months, while 66% were able to cut back on the number of
conventional cigarettes they smoked. A still smaller study of 40 smokers also finds
adding e-cigarettes helped smokers reduce the number of traditional cigarettes
they smoked each day.

2012 headline: E-cigarette use doubles in adolescents

The Centers for Disease Control announce that e-cigarette use among U.S. middle
and high school students doubles between 2011 and 2012, mirroring a similar
increase in adult use. Most alarming for policy makers: CDC concerns that vaping
among adolescents may serve as a gateway to tobacco use.

Use among middle and high school students double in a year

To measure nicotine delivery, United Kingdom researchers test 16 e-cigarettes with
an automatic smoking machine and find wide variations in nicotine levels per puff,
ranging from 0.5 to 15.4 mg. In contrast, the typical level from a tobacco puff only
ranges from 1.54 to 2.60. The wide variation between e-cigarette brands leads
researchers to question how well they can function as a nicotine replacement
device.

2013 headline: Do e-cigs really help smokers quit?

Several 2013 publications show minimal evidence that e-cigarettes help smokers
quit. A cross-sectional study of 1,836 tobacco smokers finds a significant
association with e-cig use and "unsuccessful quitter" status, but none with 'quitter"
status.
Another study of callers to state tobacco quitlines finds e-cigarette users
significantly less likely to be tobacco-free seven months after they first try vaping
compared with participants who never try e-cigarettes.
A New Zealand Health Research Council study of 657 smokers finds e-cigarettes
modestly effective in helping smokers quit. Interestingly enough, it didn't seem to
matter if they contained nicotine or not. But the results were similar to already FDA
approved nicotine patches.
Related: Nicotine in e-cigs, tobacco linked to heart disease
Some researchers worry e-cigarette use might distract smokers from proven safe
and effective methods for kicking their tobacco habit. "It's filter tipped, low tar, dj
vu all over again," say Dr. Frank Leone and Dr. Ivor Douglas in their essay "The
Emergence of E-Cigarettes: A Triumph of Wishful Thinking over Science."

2014 headline: Poison center calls skyrocket

The Centers for Disease Control release data showing the number of calls about
nicotine e-juice to poison centers rose from a scant 1 call/month in 2010 to 215
calls/month in 2014. More than half of the calls involved children under the age of 5
ingesting, inhaling or getting the substance in their eyes or on the skin.

E-liquid looks colorful and the flavors are attractive to children.

Related: FDA moves to add warnings, child-proof packaging for liquid nicotine
A study of over 75,000 Korean adolescents finds e-cigarette use to be strongly
associated with current and heavy traditional cigarette smoking. Data from the CDC
finds the use of e-cigarettes among U.S. high school students grew from 4.5% in
2013 to 13% in 2014. In that same time period, use grew among middle schoolers
from 1% to 4%.
Related FDA proposes crackdown on e-cigarettes
A study comparing the e-cigarette inhaler to the barely-used FDA approved nicotine
inhaler for smoking cessation finds the e-cig version a clear winner with users,
providing more satisfaction and a better image.
In regard to safety, a study finds e-cigarettes do contain tobacco-specific
nitrosamines and heavy metals like cadmium, nickel and lead, but the levels are 9 to
450 times lower than traditional cigarettes. The effect on lung function of glycol
derivatives found in e-cigarettes was also much less than conventional cigarettes.
Related E-cigarettes: Healthy tool or gateway device?
Still researchers aren't convinced. "Although these data suggest that e-cigarettes
may be a safer alternative to conventional cigarettes," say reviewers Bradley
Drummond and Donna Upson, "there are no data regarding the long-term cancer
risk associated with low-level exposure to the detected carcinogens. Similar to
cancer risk, there are no published data describing the long-term lung function or
cardiovascular effects of e-cigarettes."

2015 headline: Vaping could be dangerous, but perhaps a quitting aid

Is e-cigarette vapor safe?

A New England Journal of Medicine study sets off alarm bells by reporting that
some e-cigarettes release formaldehyde, a probable carcinogen, when heated by
high voltage batteries.
A Cleveland Clinic clinical review restates ongoing concerns about propylene glycol,
or PG, and the various food flavorings that are part of e-juice. While considered safe
to eat in food in small quantities, researchers say PGs have not been studied when
"inhaled deeply and repeatedly."
Another study looks at 51 of the nearly 7,000 e-cigarette flavors currently marketed
to check for a flavoring chemical called diacetyl that has been shown to be
associated with a disease calledpopcorn lung. The study finds diacetyl at higher
than laboratory normal levels in 39 of the tested flavors. Researchers call for "urgent
action" to evaluate the "potentially widespread exposure."

There are more than 7,000 flavors to choose from in today's e-cigarettes.
In December, a San Diego Veterans Affairs lab investigation Found two e-cigarette
products damaged cells in ways that could lead to cancer, even when nicotine-free.
Creating an extract from e-cig vapor, the researchers exposed cells in petri dishes.
The exposed cells showed breaks in DNA strands, which can lead to cancer, and a
greater tendency towards cell death.
However, a 2015 report by Public Health Englandencourages the medical licensing
of e-cigarettes in the UK as nicotine replacement therapy, stating that the use of

vaping is "95% safer than smoking" and "can help people to quit smoking and
reduce their cigarette consumption" even "among those not intending to quit and
rejecting other support."
And research from France's Health Barometer, which conducted telephone
interviews with over 15,000 people, finds that e-cigs "could have helped several
hundreds of thousands" quit smoking, at least temporarily.

2016 headline: Vaping a gateway to tobacco use

In late January, BMJ published a study that quizzed mpre than 2,000 Hawaiian 9th
and 10th graders about their e-cigarette and traditional cigarette use, then followed
up a year later. Nearly all of the teens (98%) knew about vaping and 68%
considered e-cigarettes to be healthier than smoking.
They found vapers were more than three times as likely to have begun smoking
cigarettes by the next year compared to "never smokers." The study also found the
effect of e-cigarettes was independent of other factors that encourage teens to pick
up the habit, such as rebelliousness and lack of parental support.
While the study showed any level of vaping led to some cigarette use, it was the
heavy vapers that were more likely to become regular cigarette smokers.
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