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We've covered e-cigarettes before, but there's new evidence, and new policies. You deserve an update. That's the topic of this week's Healthcare Triage.

This was adapted from a column I wrote for the Upshot. Links to references and further readings can be found there:

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We've covered e-cigarettes before here on Healthcare Triage but there's new evidence and new policies.  You deserve an update.  That's the topic of this week's Healthcare Triage.


Long ago, Malcolm Russell wrote, and I'm quoting, "People smoke for the nicotine, but they die from the tar."  He was referencing the fact that people get hooked on cigarettes and enjoy them for that matter because of the nicotine buzz that accompanies their use.  The nicotine doesn't give them cancer and lung disease, though.  It's the tar and other stuff in traditional cigarettes that carries the harm.

Electronic cigarettes, or e-cigarettes, carry the potential promise of delivering the nicotine many seem to want without the dangerous additives that come with smoke.  The use of e-cigarettes by youth has increased dramatically in recent years.  In 2011, about 1.5% of high school students reported using them in the last month.  In 2014, more than 12% of students did.  By 2014, this means that nearly 2.5 million middle and high school students in the US had used them in the past month.

This is concerning because nicotine is not considered safe for children and adolescents.  Poisoning is possible.  It's thought that nicotine interferes with brain development.  Most concerning, it's believed that becoming addicted to nicotine in any form makes smoking more likely later in life.  Moreover, it's not settled that e-cigarettes are completely safe.  Enough research exists about e-cigarettes to have warranted a number of systematic reviews and meta-analyses. 

E-cigarettes are perceived to be less harmful than conventional cigarettes, and they are thought to be useful quit aids.  Those perceptions, however, are not always fully grounded in evidence.  A 2014 study in the journal Circulation analyzed the data from a number of angles.  For instance, they found that the aerosol from e-cigarettes was significantly lower in toxicants than conventional cigarettes, although toxicants could still be detected.   Those exposed secondhand were also at much lower risk from e-cigarettes than traditional ones, though some risk might still be there.  In other words, we shouldn't believe that electronic cigarettes result in the inhalation of harmless water vapor, but they're likely safer than conventional cigarettes.

Another review published later that year came to somewhat similar conclusions.  They noticed that at least a third of the articles had authors with conflicts of interest.  They reported that studies found concerning compounds in the aerosol, especially in the flavorings and propylene glycol, which aren't a part of conventional cigarettes.  

The authors concluded that e-cigarettes can't be deemed safe even if they are much less harmful than conventional cigarettes.  We conducted our own mini-review on Healthcare Triage a couple years ago and came to the same conclusion, but many public health officials believe that cigarettes are one of the most significant public health threats in existence.  Electronic cigarettes don't appear to be in the same league.

Some have argued that e-cigarettes can help people to quit smoking, much like nicotine patches or gum do.  A 2015 study in PLOS One reviewed the evidence.  Among 1242 smokers, 18% reported quitting conventional cigarettes for at least six months, which was significantly better than those using placebos.  E-cigarette use was also associated with a reduction in the number of cigarettes smoked per day.  Only two studies were randomized controlled trials however, and they were of mixed quality.  

Most important, these studies really didn't compare the usefulness of e-cigarettes for quitting against other quit measures, like medications or nicotine replacement therapy.  It's possible that those are more powerful. 

Some argue that the use of e-cigarettes may be a gateway to later conventional cigarette use.  A meta-analyses from early this year examined how people used both types of cigarettes.  They found that current smokers were significantly more likely to use e-cigarettes and conventional cigarettes together.  This was even truer in adolescents.  In fact, the paper said, and I'm quoting, "The use of e-cigarettes does not discourage and may encourage conventional cigarette use."

In other countries such as the UK, they're taking the opposite approach.  They're actively encouraging smokers to switch to e-cigarettes.  I admit to being conflicted here.  Of course I'd rather no adolescents use either conventional or e-cigarettes, but I'm somewhat swayed by the arguments of those who advocate for harm reduction.  

Years ago, pediatricians used to advocate only for smoking cessation in parents because it carried a health risk for their children.  Then some enterprising researcher showed that if smoking parents would just agree to smoke at least three meters away from their infant, it could reduce hospitalization of infants in their first 18 months of life significantly.  Now pediatricians still advocate for quitting, but they also talk about smoking outside away from babies.  We don't want to make the perfect the enemy of the good, and of course, most pediatricians including myself would advocate for adolescents to use condoms if they have sex rather than preach abstinence only.  We're capable of discussing harm reduction.

One of the questions that few want to consider however is whether we'd rather kids smoke conventional cigarettes or e-cigarettes.  Neither would be preferable, but a recent study in The Journal of Health Economics forces us to answer this question.  The results showed that in states that banned e-cigarette sales to minors, there was a significant increase of almost 1% point in conventional cigarette smoking.  This is disturbing.  Cigarette sales have been dropping throughout the country, but in the states that implemented bans on e-cigarette sales to minors, the decrease in conventional cigarette use slowed by about 70%.  

Moreover, it's still easy to get your hands on e-cigarettes if you want 'em.  In 2013, North Carolina passed an e-cigarette age verification law.  In 2014, researchers in that state supervised 14-17 year olds purchasing e-cigarettes on 98 of the 103 most popular online internet vendors.  The kids were able to get successful deliveries with no age checks from 75% of them, but that's 'cause some of the websites didn't function.  Of those vendors with functioning websites, kids were able to purchase e-cigarettes about 94% of the time.

Our overall goal should be to get kids and adolescents to quit all types of smoking period.  Short of that, we should aim to improve the health of as many children as possible.  Banning sales of e-cigarettes to minors may achieve that goal, but it's also possible it may not.  It may also backfire.  Further studies and a careful eye on nicotine use in all its forms are warranted.

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