What are E-Cigarettes?

E-cigarettes, or nicotine vapes, are electronic devices used to deliver nicotine to the user’s lungs, where it can be readily absorbed. Nicotine is the addictive chemical found in tobacco products. At its most basic, an e-cigarette is composed of a mouthpiece, a cartridge, a heating element, and a battery. The cartridge holds the e-liquid, in other words a mixture of nicotine, water, vegetable glycerin or propylene glycol (or both), and flavorings. When activated, the heating element draws on the battery’s power to turn the liquid into vapor, where it is then pulled into the user’s lungs via the mouthpiece. 

Proliferation in the US

The first mention of an e-cigarette occurs in a patent from 1930, which was never commercialized. In 1998, a major US tobacco company requested Food and Drug Administration approval to bring their version of the e-cigarette to the market, which the FDA denied on the basis of it being an unapproved drug delivery system. This resulted in a lull in the market for nicotine vaporizers, but momentum resumed in 2003 in Beijing, China, with the first commercially successful rendition of the e-cigarette. E-cigarettes were introduced to Europe and the United States in 2006. In the years since 2006 there has been a flurry of commercial success for e-cigarettes, and they are now a popular consumer product in the US, with ongoing research as to their health effects and how they are best regulated.

Impact on Health

Because e-cigarettes only gained commercial success in the early 2000s, there is limited long-term data on the health effects of vaping nicotine. That means there are no certain long-term conclusions about health that can be drawn. However, assumptions can be extrapolated from available long-term data on similar types of exposure, such as exposure to artificial fog machines or food vapors in a factory setting. 

• Flavoring agents: One such example is a condition commonly called “popcorn lung”, a form of life-threatening respiratory failure so named because it was first observed in popcorn factory workers who had inhaled a flavoring agent called diacetyl. Diacetyl was found in the majority of sweet e-liquids evaluated by one study. Many ingredients in e-liquids, like diacetyl, are rated by the FDA as “generally recognized as safe” (GRAS) when eaten but are untested for inhalation in an aerosolized form. This is true of vegetable glycerin and propylene glycol as well, and these knowledge gaps are common when it comes to e-cigarettes. 
• Product labeling issues: There are also numerous inconsistencies in product labeling, making it even more difficult to know exactly what one is inhaling. Nicotine concentrations in e-liquid, for one, have frequently been found to differ from the labeling. E-liquid typically contains 16-24 mg/ml of nicotine, although the available concentrations range from 12-100 mg/ml. The average cigarette, on the other hand, delivers approximately 2 mg of nicotine to the smoker, and the median fatal dosage for an adult is around 60 mg. High concentrations of nicotine in e-liquid have caused an increasing frequency of nicotine poisoning from accidental ingestion of e-liquids among children and adults. 
• Metal leakage: The frequent heating and cooling process of the e-cigarette heating element can cause metals such as chromium, manganese, nickel, and lead to gradually leech into the e-liquid as the heating coil breaks down. Inhalation of these metallic fumes by welders is known to increase respiratory illness and possibly increase the incidence of lung cancer. A similar phenomenon could be extrapolated to e-cigarette users, although more research is required. 
• Other ingredients: Overall, e-cigarettes contain lower levels of carcinogens than conventional cigarettes, but comparable levels of ultrafine particles and other toxins that affect cardiovascular health and account for half of smoking related illnesses.

Enforcement of E-Cigarettes

From a public health standpoint, e-cigarettes present a challenge in that it is difficult to regulate indoor vaping or create “smoke free” areas, since e-vapor disappears quickly and the scents are not unique to e-cigarettes. A recent study found that 60% of e-cigarette users vape in “no smoking” areas, and e-cigarette vapor has been found to lower indoor air quality and result in similar levels of nicotine absorption in bystanders as second-hand cigarette smoke does. In recent years, there has been an increase in regulation surrounding vaping in public places, but enforcement is not easy.

E-Cigarettes as a Cigarette Substitution

E-cigarettes have the potential to be used as a smoking cessation aid, since research thus far shows them to be less dangerous than a traditional combustible cigarette, and the customizable dosage of nicotine they deliver can help ease a smoker’s transition off of traditional cigarettes. However, several meta-analyses show that they are only helpful in a specific context. E-cigarettes purchased over-the-counter as a consumer product by current smokers, both those who were motivated to quit smoking and those who were not, are not associated with increased smoking cessation among adults. However, when they are provided to smokers motivated to quit as a free therapeutic tool, they do result in a higher success of smoking cessation. Another meta-analysis found that there were a few studies that showed the opposite effect, although the authors stated that these studies did not account for the frequency of use. Higher frequency vaping is associated with more successful cigarette cessation. All studies concerning this topic emphasized that e-cigarettes are safer than combustible cigarettes, but not risk free either. It was unusual for people who had quit smoking with the help of a nicotine vape to then go on to quit vaping as well, with 80% of quitters continuing to vape. These studies suggest that regulatory authorities should make e-cigarettes available as a prescription therapy for current cigarette smokers, rather than a widely available over-the-counter recreational product. However, the unknowns when it comes to the long-term effects of vaping make employing the technology in a therapeutic context risky. 

Despite therapeutic potential for smokers attempting to quit combustible cigarettes, there is some evidence that e-cigarettes have the effect of introducing non-smokers to nicotine, which is counterproductive from a public health standpoint. Youth e-cigarette use doubled or tripled every year between 2011-2014, and by 2014 e-cigarette use in youths had surpassed traditional cigarette use. Twenty-five percent of youths using e-cigarettes did not match the risk profile of youth cigarette smokers, suggesting that they would not have been introduced to nicotine if it had not been for the novelty, flavor variety, and perceived harmlessness of vaping, all of which are cited as unique reasons that youths are attracted to vaping.

Public Health Debates

Despite the e-cigarette being a relatively new commercial product, there is public contention regarding whether the therapeutic benefits of e-cigarettes outweigh the public health risks. There are generally two camps when it comes to assessing the risks and rewards of e-cigarettes: The first is concerned with easing the health burden on people already addicted to traditional combustible cigarettes, the other is concerned with preventing nicotine addiction in the non-smoking population. According to available data, traditional cigarettes are almost unanimously viewed as more harmful to the user than e-cigarettes. For this reason, if therapeutic nicotine vapes are a successful aid for traditional cigarette cessation, then their availability would help decrease the negative health burdens of combustible cigarettes. On the flip side, widely available nicotine vapes can also expose non-users to nicotine for the first time. So, in analyzing how e-cigarettes should be regulated, public health officials must determine how different forms of regulation impact the health of these two separate risk groups.

Regulating E-Cigarettes

The primary law regulating e-cigarettes in the United States is the federal Tobacco 21 law (T21). It was signed into place in 2019 by former president Donald Trump, and prohibits the sale of tobacco products, including e-cigarettes, to anyone under the age of 21 years. Although some state codes still list 18 years as the legal age to purchase tobacco products, federal law prevails in this case. T21 is a blanket regulation for the entire country, but individual states can tax e-cigarettes and other products deemed harmful to the general public. This type of tax is often referred to as a “sin tax,” and these taxes fall under the authority of state governments. Some items that are typically taxed to correct for their societal harm include tobacco, alcohol, and gambling. By raising the prices on these items through taxation, state governments can deter people from purchasing them even if they are legally allowed to do so. Further, the money generated by this “sin tax” can hypothetically go towards undoing some of the damage these products do to society, such as helping to pay for state tobacco control programs. In February 2020, the FDA issued a ban on the sale of cartridge-based e-cigarettes in flavors other than tobacco and menthol, since the more novel flavors, like fruit- and dessert-based flavors, were shown to be one of the features that spurred youths to take up vaping. Some states have further regulations surrounding where it is acceptable to vape, such as rules prohibiting vaping in “smoke free” areas, or within 500 feet of a premises primarily occupied by youths.

In 2006 when e-cigarettes were first making their commercial debut, they entered the market unregulated. As lawmakers were beginning to catch on to the risks of unregulated e-cigarettes, massive cigarette companies also entered the market, and their influence hindered legislative efforts. The initial opposition to state and local level regulation came from e-cigarette users and independent retailers, but the interference of large tobacco companies shifted the dynamics towards those of the tobacco control debates spanning the 1970s-1990s. These debates often cited “imminent” federal regulation which would render state policy obsolete, and used lobbying and campaign contributions to influence state-level regulation surrounding e-cigarettes.
Another way that the government influences e-cigarette consumption is through projects like the FDA’s “The Real Cost” campaign, which uses scare-tactic advertising to mold the newer generation’s perception of smoking, targeting those aged 12-17 years. In 2017 the FDA pivoted from anti-cigarette messaging to launching a $60 million anti-vaping campaign, which follows the data revealing that e-cigarettes have been the primary form of nicotine consumption for youths since 2014. This campaign is some of the only federal intervention that targets the consumption side of e-cigarettes rather than the retail side, and has been compared to the 1936 anti-cannabis propaganda film “Reefer Madness”. This tactic may reduce vaping in youths, but it has the dual effect of spreading the inaccurate perception that e-cigs are equally or more harmful than traditional cigarettes, which can discourage adult smokers from using vaping as a quitting aid.