E-cigarettes – revisited
Since our last update about nicotine-containing e-cigarettes, there has been an explosion of research published and a variety of steps taken by governments. Today’s brief provides a quick summary of a few of those findings and activities.
In the past 18 months, several hundred research papers have been published, with some interesting work focused on use of e-cigarettes as smoking cessation aids. One report of particular interest was a cross-sectional population study of 5,863 adult smokers who had the intention to quit, which revealed that e-cigarette users were more likely to report continued abstinence than the users of either nicotine replacement therapies or other smoking cessation aids.1 Another prospective controlled randomized clinical trial in a sample of smokers who were not intending to quit, indicated levels of smoking reduction and abstinence resulting from the replacement of cigarettes with e-cigarettes.2 These findings can be contrasted with the results of the 2011–2013 US National Youth Tobacco Survey of students in grades 6–12 who had never smoked, the latter survey showing that the intention to use traditional cigarettes was higher among e-cigarette users than among those who never used e-cigarettes;3 another recent population-based study from California cautions that smokers who used e-cigarettes might be at higher risk of not quitting smoking.4 Clearly, more work is required to understand these complex relationships. More information on e-cigarette consumption in Canada has also become available through the 2013 Canadian Tobacco, Alcohol and Drugs Survey (CTADS). These data show that 2.5 million Canadians aged 15 and older (9%) have tried an e-cigarette, while 20% of youth aged 15-19 and 20-24 have tried them.5
There have also been a number of research studies that looked at the possible toxic effects of e-cigarette liquids and aerosols. One of these studies has shown very low in vitro cytotoxicity,6 while another has shown adverse physiological effects after short-term in vivo exposure.7 This work is still in its infancy; as such, it is too early to develop conclusions regarding possible long-term effects. In order to achieve a balanced perspective, these data should also be compared to data on the effects of cigarette smoking.
Some of the most interesting changes have come on the political landscape. In an effort to respond to the increasing popularity of e-cigarettes in Canada, provincial health authorities in Ontario, British Columbia, Nova Scotia and Quebec have established restrictions on e-cigarettes.8-10 Their legislations place e-cigarettes under provincial Tobacco Acts, subjecting them to prohibitions on use in public places and placing limitations on the age requirement for sales and marketing.9-12
Two interesting reports from federal governments in different countries have been published. The first is the House of Commons’ Standing Committee on Health, Environment and Social Affairs (HESA) report on their review of e-cigarettes in Canada.13 It summarized the findings from a series of hearings that sought the opinion of a cross-section of stakeholders, including CPHA. This report, released in March, called for a new legislative framework for nicotine- and non-nicotine-containing e-cigarettes that would prohibit their use in federally regulated public spaces; restrict promotional and marketing activities; disclose information related to ingredients; place an age limit on purchasers; and ensure that the products are visually distinct.13 The second is a recent report by Public Health England (PHE) endorsing the potential of e-cigarettes as a smoking cessation aid.14 That report emphasized that the adult and youth smoking rates in England have steadily declined over the years, while e-cigarettes became the most popular cessation aid: their use has risen sharply over the last 5 years in England and they are now used by approximately 35% of those trying to quit. PHE’s prediction, therefore, is that nicotine-containing e-cigarettes will significantly contribute to achieving the department of health’s goal of a tobacco-free generation by 2025.14
E-cigarettes continue to be a challenging public health issue. Effective policy and legislation continue to be hindered by a lack of integrated evidence to support decision-making, as well as a tendency to equate e-cigarettes with cigarettes. Moreover, novel control strategies, including the notion of differential taxation on all nicotine-containing products, based on their relative harmfulness, should be considered as an approach to better regulating nicotine-containing e-cigarettes.15
- Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: A cross-sectional population study. Addiction 2014;109:1531–40.
- Caponnetto P, Campagna D, Cibella F, Morjaria JB, Caruso M, Russo C, et al. Efficiency and safety of an electronic cigarette (ECLAT) as tobacco cigarettes substitute: A prospective 12-month randomized control design study. PLOS ONE 2013;8(6):e66317.
- Bunnell RE, Agaku IT, Arrazola RA, Apelberg BJ, Caraballo RS, Corey CG, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res 2015;17(2):228–35.
- Al-Delaimy WK, Myers MG, Leas EC, Strong DR, Hofstetter R. E-cigarette use in the past and quitting behavior in the future: A population-based study. Am J Public Health 2015;105(6):1213–19.
- Government of Canada. Summary of results for 2013: Canadian Tobacco, Alcohol and Drugs Survey (CTADS). Statistics Canada, 2015. Available at: healthycanadians.gc.ca/science-research-sciences-recherches/data-donnees/ctads-ectad/summary-sommaire-2013-eng.php (Accessed September 22, 2015).
- Misra M, Leverette RD, Cooper BT, Bennett MB, Brown SE. Comparative in vitro toxicity profile of electronic and tobacco cigarettes, smokeless tobacco and nicotine replacement therapy products: E-liquids, extracts and collected aerosols. Int J Environ Res Public Health 2014; 11(11):11325–47.
- Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK. Short-term pulmonary effects of using an electronic cigarette: Impact on respiratory flow resistance, impedance, and exhaled nitric oxide. CHEST 2012; 141(6):1400–6.
- Obourn E. E-cigarette use slapped with growing provincial regulation. CBC News 2014 Dec 22. Available at: www.cbc.ca/news/business/e-cigarette-use-slapped-with-growing-provincial-regulation-1.2879168 (Accessed September 22, 2015).
- Branswell H. Provinces move to regulate e-cigarettes as Ottawa studies issue. The Globe and Mail 2015 May 12. Available at: www.theglobeandmail.com/life/health-and-fitness/health/provinces-move-to-regulate-e-cigarettes-as-ottawa-studies-issue/article24402414/ (Accessed September 22, 2015).
- Government Operations, Health. Legislation enhanced to regulate e-cigarette. British Columbia Newsroom 2015 March 5. Available at: news.gov.bc.ca/stories/legislation-enhanced-to-regulate-e-cigarettes (Accessed September 22, 2015).
- Damerla D. Bill 45, Making Healthier Choices Act, 2015. Ontario: Legislative Assembly of Ontario. Available at: www.ontla.on.ca/web/bills/bills_detail.do?BillID=3080 (Accessed September 22, 2015).
- CBC News. Quebec on e-cigarettes: No sale to minors, no ‘vaping’ in public. 2014 Aug 16. Available at: www.cbc.ca/news/canada/montreal/quebec-on-e-cigarettes-no-sale-to-minors-no-vaping-in-public-1.2738537 (Accessed September 22, 2015).
- Parliament of Canada. Vaping: Toward a Regulatory Framework for E-Cigarettes. Committee Report, 2015. Available at: www.parl.gc.ca/HousePublications/Publication.aspx?DocId=7862816&Language=E&Mode=1&Parl=41&Sec=2&File=18 (Accessed September 23, 2015).
- Public Health England. E-cigarettes: A new foundation for evidence-based policy and practice. PHE publications gateway number: 2015260. London: Department of Health, 2015 Aug.
- Chaloupka FJ, Sweanor D, Warner KE. Differential taxes for differential risks — Toward reduced harm from nicotine-yielding products. NEJM 2015;373(7):594–97.