Electronic Cigarettes Revisted: Public Health and Medical Opinion

A few weeks ago I posted a little essay here on “electronic cigarettes,” alleging that this relatively new nicotine delivery device might be more dangerous in various ways than some of the aggressive marketing of “e-cigs” might portray. Given the nefarious history of tobacco and smoking wars in this country and beyond, that one seemed fairly innocuous at the time.
However, the response from quite a few readers was vehement, and often less than complimentary – in fact, there was more angry response than anything I’d written on since gun control issues. Not all the input was critical – some readers had used e-cigs to quite or curtail tobacco smoking – a good thing, obviously, and evidence that the product can be used for “harm reduction” purposes in some cases. Some folks in the e-cig industry thanked me for critiquing the less ethical among their colleagues. Some clinicians were glad to see confirmation of their suspicion that e-cigs were being marketed to kids, who were using them and then wound up smoking regular cigarettes, as I had also noted.
But others accused me of all manner of perfidy, stupidity, and so forth. Others “yelled” at me in all caps while calling me things like “blowhard” – without sensing the irony, it seemed. I did learn new things from some of the comments, and would have written the original post differently in light of that information – in essence, the subtitle should have been “A Pack of Lies?” – with a question mark added, as I was trying to raise questions about safety, funding, regulation, and the so forth. I said nothing about favoring banning the product – at this time, anyway – but that we needed to be more cautious in allowing the open marketing, sales, and use.
But perhaps I should have just waited for our local health and medical authorities to weigh in, as they now have. The following policy statement has just been adopted by the San Francisco Health Commission, at the request of the San Francisco Department of Public Health, with the full endorsement of the San Francisco Medical Society’s board of (physician) directors. Clearly there are multiple sides to this story, and we have more to learn, but in the meantime, a cautious approach is warrented, as reflected in this new statement. It’s a long one (and for the record, I had no input on it), but for those interested, here it is.
Health Commission City and County of San Francisco Resolution No. 7-11
Endorsing the San Francisco Department of Public Health Proposal to Regulate Electronic Cigarettes
WHEREAS the United States Food and Drug Administration (FDA) has not yet issued any regulations regarding electronic cigarettes, also called e-cigarettes, and these products are available for purchase in this city; and
WHEREAS the U.S. Court of Appeals for the D.C. Circuit recently issued a decision that e-cigarettes and other products “made or derived from tobacco” can be regulated as “tobacco products” under the Federal Food, Drug, and Cosmetic Act, but that these products cannot be regulated as drugs/devices unless they are marketed for therapeutic purposes; and
WHEREAS electronic cigarette manufacturers and retailers are making unproven health claims about their products by asserting that they are safe or safer than traditional cigarettes and that they can be used as an aid to smoking cessation; and
WHEREAS the FDA has warned the public about the potential health risks of using electronic cigarettes; and
WHEREAS initial FDA studies found that electronic cigarettes contain known carcinogens; and
WHEREAS the FDA issued a statement on April 25, 2011 that it intends to propose a regulation that would extend the Agency’s “tobacco product” authority under the Family Smoking Prevention and Tobacco Control Act to other categories of tobacco products that meet the statutory definition of “tobacco product” under the Act; and
WHEREAS electronic cigarette packages do not supply any warnings about possible adverse effects on health comparable to FDA-approved nicotine replacement products or conventional cigarettes; and
WHEREAS there is no scientific evidence that electronic cigarettes can help smokers to quit smoking; and
WHEREAS the World Health Association does not consider electronic cigarettes to be a legitimate therapy for smokers trying to quit tobacco; and
WHEREAS FDA studies found that certain electronic cigarettes misrepresent nicotine content on their labels and sometimes contain far more nicotine than FDA-approved smoking cessation products; and
WHEREAS FDA studies found that certain electronic cigarettes emitted a markedly different amount of nicotine with each puff; and
WHEREAS the Surgeon General has found that the chemical nicotine is a powerful pharmacologic agent that acts in the brain and throughout the body and is highly addictive; and
WHEREAS withdrawal symptoms from nicotine include cognitive and attention defects, cravings, inability to sleep, and sleep disturbance; and
WHEREAS use of nicotine may cause or contribute to cardiovascular disease, complications of hypertension, reproductive disorders, cancer, and gastrointestinal disorders, including peptic ulcer disease and gastro esophageal reflux; and
WHEREAS electronic cigarettes may not be legally sold to minors in California; and
WHEREAS some electronic cigarette producers market their product to children by flavoring their products with candy, fruit, and other flavors popular with children; and
WHEREAS the FDA has raised concerns that electronic cigarettes, including but not limited to flavored electronic cigarettes, can increase nicotine addiction among young people and may lead youth to try conventional tobacco products; and
WHEREAS according to the 2009 San Francisco Unified School District High School Youth Risk Behavior Survey, 10.4% of San Francisco high school students reported current cigarette use; according to the 2009 California Health Interview Survey, 11.9% of San Francisco adults were current smokers, and according to the 2008 California Adult Tobacco Survey, 17.6% of California adults 18-24 years of age were current smokers; and
WHEREAS there is no evidence that the vapors released into the air through the use of an electronic cigarette do not present a danger to others who breathe them; and
WHEREAS electronic cigarettes’ resemblance to conventional cigarettes has caused the San Francisco Airport Health and Safety Office and Department of Public Health Secondhand Smoke Prevention and Enforcement Program to observe that the use of electronic cigarettes in places where smoking is prohibited increases the likelihood that people will break the law by lighting up cigarettes because they see what appears to be someone smoking, undermining compliance with existing smoking regulations; and
WHEREAS the use of an electronic cigarette in public is virtually indistinguishable from the use of traditional tobacco products in public, prompting confusion and concern by the owners of establishments seeking to comply with the City’s laws prohibiting smoking in certain locations; and
WHEREAS the Department of Transportation has banned the use of electronic cigarettes on U.S. carrier and foreign carrier flights in scheduled intrastate, interstate, and foreign air transportation; and
WHEREAS on April 5, 2011 the San Francisco Airport Commission amended its Rules and Regulations regarding smoking to include a ban on the use of electronic cigarettes due to the problems associated with electronic cigarette use in public outlined above; and
WHEREAS the American Cancer Society Cancer Action Network, American Heart Association, Campaign for Tobacco Free Kids, and American Lung Association support including electronic cigarettes in smoke-free laws; and
WHEREAS electronic cigarettes have been banned in indoor public places and workplaces by King County (Seattle), Washington, New Jersey and Suffolk County, New York while electronic cigarette sales have been banned throughout Canada; now therefore be it
RESOLVED, that the Health Commission endorses the policies proposed by the San Francisco Department of Public Health to
1. Prohibit the use of electronic cigarettes (and other nicotine delivery devices not approved by the FDA as smoking cessation aids) in those areas where smoking is prohibited in the San Francisco Health Code.
2. Require a tobacco permit for the sale or furnishing of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids.
– That’s it, although the many references are available in the online version:
I expect that many who have read this far – if anyone does – will include previous readers, and that some won’t like it. But some had asked for better information and what doctors think; here it is.
ps: If you intend to comment here, please do indicate who you really are, with a real name, and whether you have any financial or other stake in the sale or use of tobacco or e-cigs. Seems only fair to me (My name is above; I have no such conflict of interest).
pps: For other tobacco-related news, see:

A new study in the CDC’s Morbidity and Mortality Weekly Report, “Smoking in Top-Grossing Movies, United States’ 2010,” shows promise for the ability of movie producers to positively affect young people’s health by reducing the number of teens who smoke. The American Academy of Pediatrics (AAP) calls on all movie producers to adopt policies that create a healthier movie experience for kids.
For more information, visit http://www.aap.org/richmondcenter/smokefreemovies.html
By: Steve Heilig

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