A Hot Debate Over E-Cigarettes as a Path to Tobacco, or From It

By SABRINA TAVERNISEFEB

Dr. Michael Siegel, a hard-charging public health researcher at Boston University, argues that e-cigarettes could be the beginning of the end of smoking in America. He sees them as a disruptive innovation that could make cigarettes obsolete, like the computer did to the typewriter.

But his former teacher and mentor, Stanton A. Glantz, a professor of medicine at the University of California, San Francisco, is convinced that e-cigarettes may erase the hard-won progress achieved over the last half-century in reducing smoking. He predicts that the modern gadgetry will be a glittering gateway to the deadly, old-fashioned habit for children, and that adult smokers will stay hooked longer now that they can get a nicotine fix at their desks.

These experts represent the two camps now at war over the public health implications of e-cigarettes. The devices, intended to feed nicotine addiction without the toxic tar of conventional cigarettes, have divided a normally sedate public health community that had long been united in the fight against smoking and Big Tobacco.

Dr. Michael Siegel, a public health researcher, says that e-cigarettes could help end smoking. Credit Matthew Cavanaugh for The New York Times The essence of their disagreement comes down to a simple question: Will e-cigarettes cause more or fewer people to smoke? The answer matters. Cigarette smoking is still the single largest cause of preventable death in the United States, killing about 480,000 people a year.

Dr. Siegel, whose graduate school manuscripts Dr. Glantz used to read, says e-cigarette pessimists are stuck on the idea that anything that looks like smoking is bad. “They are so blinded by this ideology that they are not able to see e-cigarettes objectively,” he said. Dr. Glantz disagrees. “E-cigarettes seem like a good idea,” he said, “but they aren’t.”

Science that might resolve questions about e-cigarettes is still developing, and many experts agree that the evidence so far is too skimpy to draw definitive conclusions about the long-term effects of the devices on the broader population.

“The popularity is outpacing the knowledge,” said Dr. Michael B. Steinberg, associate professor of medicine at the Robert Wood Johnson Medical School at Rutgers University. “We’ll have a better idea in another year or two of how safe these products are, but the question is, will the horse be out of the barn by then?”

This high-stakes debate over what e-cigarettes mean for the nation’s 42 million smokers comes at a crucial moment. Soon, the Food and Drug Administration is expected to issue regulations that would give the agency control over the devices, which have had explosive growth virtually free of any federal oversight. (Some cities, like Boston and New York, and states, like New Jersey and Utah, have already weighed in, enacting bans in public places.)

The new federal rules will have broad implications for public health. If they are too tough, experts say, they risk snuffing out small e-cigarette companies in favor of Big Tobacco, which has recently entered the e-cigarette business. If they are too lax, sloppy manufacturing could lead to devices that do not work properly or even harm people.

And many scientists say e-cigarettes will be truly effective in reducing the death toll from smoking only with the right kind of federal regulation — for example, rules that make ordinary cigarettes more expensive than e-cigarettes, or that reduce the amount of nicotine in ordinary cigarettes so smokers turn to e-cigarettes for their nicotine.

“E-cigarettes are not a miracle cure,” said David B. Abrams, executive director of the Schroeder National Institute for Tobacco Research and Policy Studies at the Legacy Foundation, an antismoking research group. “They need a little help to eclipse cigarettes, which are still the most satisfying and deadly product ever made.”

Smoking is already undergoing a rapid evolution. Nicotine, the powerful stimulant that makes traditional cigarettes addictive, is the crucial ingredient in e-cigarettes, whose current incarnation was developed by a Chinese pharmacist whose father died of lung cancer. With e-cigarettes, nicotine is inhaled through a liquid that is heated into vapor. New research suggests that e-cigarettes deliver nicotine faster than gum or lozenges, two therapies that have never quite taken off.

Sales of e-cigarettes more than doubled last year from 2012, to $1.7 billion, according to Bonnie Herzog, an analyst at Wells Fargo Securities. Ms. Herzog said that in the next decade, consumption of e-cigarettes could outstrip that of conventional cigarettes. The number of stores that sell them has quadrupled in just the last year, according to the Smoke Free Alternatives Trade Association, an e-cigarette industry trade group.

“E-cigarette users sure seem to be speaking with their pocketbooks,” said Mitchell Zeller, director of the F.D.A.’s Center for Tobacco Products. Public health experts like to say that people smoke for the nicotine but die from the tar. And the reason e-cigarettes have caused such a stir is that they take the deadly tar out of the equation while offering the nicotine fix and the sensation of smoking. For all that is unknown about the new devices — they have been on the American market for only seven years — most researchers agree that puffing on one is far less harmful than smoking a traditional cigarette.

But then their views diverge.

Pessimists like Dr. Glantz say that while e-cigarettes might be good in theory, they are bad in practice. The vast majority of people who smoke them now also smoke conventional cigarettes, he said, and there is little evidence that much switching is happening. E-cigarettes may even prolong the habit, he said, by offering a dose of nicotine at times when getting one from a traditional cigarette is inconvenient or illegal.

What is more, critics say, they make smoking look alluring again, with images on billboards and television ads for the first time in decades. Dr. Glantz says that only about half the people alive today have ever seen a broadcast ad for cigarettes. “I feel like I’ve gotten into a time machine and gone back to the 1980s,” he said.

Researchers also worry that e-cigarettes could be a gateway to traditional cigarettes for young people. The devices are sold on the Internet. The liquids that make their vapor come in flavors like mango and watermelon. Celebrities smoke them: Julia Louis-Dreyfus and Leonardo DiCaprio puffed on them at the Golden Globe Awards.

A survey from the Centers for Disease Control and Prevention found that in 2012, about 10 percent of high school students said they had tried an e-cigarette, up from 5 percent in 2011. But 7 percent of those who had tried e-cigarettes said they had never smoked a traditional cigarette, prompting concern that e-cigarettes were, in fact, becoming a gateway.

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Articles in this series will examine the multibillion-dollar market for e-cigarettes and the consequences for public health.

“I think the precautionary principle — better safe than sorry — rules here,” said Dr. Thomas Frieden, director of the C.D.C.

E-cigarette skeptics have also raised concerns about nicotine addiction. But many researchers say that the nicotine by itself is not a serious health hazard. Nicotine-replacement therapies like lozenges and patches have been used for years. Some even argue that nicotine is a lot like caffeine: an addictive substance that stimulates the mind.

“Nicotine may have some adverse health effects, but they are relatively minor,” said Dr. Neal L. Benowitz, a professor of medicine at the University of California, San Francisco, who has spent his career studying the pharmacology of nicotine.

Another ingredient, propylene glycol, the vapor that e-cigarettes emit — whose main alternative use is as fake smoke on concert and theater stages — is a lung irritant, and the effects of inhaling it over time are a concern, Dr. Benowitz said.

But Dr. Siegel and others contend that some public health experts, after a single-minded battle against smoking that has run for decades, are too inflexible about e-cigarettes. The strategy should be to reduce harm from conventional cigarettes, and e-cigarettes offer a way to do that, he said, much in the way that giving clean needles to intravenous drug users reduces their odds of getting infected with the virus that causes AIDS.

Solid evidence about e-cigarettes is limited. A clinical trial in New Zealand, which many researchers regard as the most reliable study to date, found that after six months about 7 percent of people given e-cigarettes had quit smoking, a slightly better rate than those with patches. Do you care about someone who smokes?

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“The findings were intriguing but nothing to write home about yet,” said Thomas J. Glynn, a researcher at the American Cancer Society.

In Britain, where the regulatory process is more developed than in the United States, researchers say that smoking trends are heading in the right direction.

“Motivation to quit is up, success of quit attempts are up, and prevalence is coming down faster than it has for the last six or seven years,” said Robert West, director of tobacco studies at University College London. It is impossible to know whether e-cigarettes drove the changes, he said, but “we can certainly say they are not undermining quitting.”

The scientific uncertainties have intensified the public health fight, with each side seizing on scraps of new data to bolster its position. One recent study in Germany on secondhand vapor from e-cigarettes prompted Dr. Glantz to write on his blog, “More evidence that e-cigs cause substantial air pollution.” Dr. Siegel highlighted the same study, concluding that it showed “no evidence of a significant public health hazard.”

That Big Tobacco is now selling e-cigarettes has contributed to skepticism among experts and advocates.

Cigarettes went into broad use in the 1920s — and by the 1940s, lung cancer rates had exploded. More Americans have died from smoking than in all the wars the United States has fought. Smoking rates have declined sharply since the 1960s, when about half of all men and a third of women smoked. But progress has slowed, with a smoking rate now of around 18 percent.

“Part of the furniture for us is that the tobacco industry is evil and everything they do has to be opposed,” said John Britton, a professor of epidemiology at the University of Nottingham in England, and the director for the U.K. Center for Tobacco and Alcohol Studies. “But one doesn’t want that to get in the way of public health.”

Carefully devised federal regulations might channel the marketing might of major tobacco companies into e-cigarettes, cannibalizing sales of traditional cigarettes, Dr. Abrams of the Schroeder Institute said. “We need a jujitsu move to take their own weight and use it against them,” he said.

Dr. Benowitz said he could see a situation under which the F.D.A. would gradually reduce the nicotine levels allowable in traditional cigarettes, pushing smokers to e-cigarettes.

“If we make it too hard for this experiment to continue, we’ve wasted an opportunity that could eventually save millions of lives,” Dr. Siegel said.

Dr. Glantz disagreed. “I frankly think the fault line will be gone in another year,” he said. “The evidence will show their true colors.” Do you care about someone who smokes?

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How e-cigarettes could save lives

By Sally Satel, Published: February 14

Sally Satel is a resident scholar at the American Enterprise Institute and a psychiatrist specializing in addiction. She has served as an expert witness in tobacco litigation.

Should electronic cigarettes be regulated like tobacco products, emblazoned with warnings and subject to tight marketing restrictions? Those are among the questions before the Food and Drug Administration as it decides in the coming weeks how to handle the battery-powered cigarette mimics that have become a $1.5 billion business in the United States.

Groups promoting intensive regulation include the American Lung Association and the Campaign for Tobacco-Free Kids. They worry that the health risks haven’t been fully established and that e-cigarettes will make smoking commonplace again, especially among teens. They are quick to push back in response to anything that might make e-cigarettes more attractive, such as the NJOY King ad that aired during the Super Bowl or when actors Leonardo DiCaprio and Julia Louis-Dreyfus were shown “vaping” at the Golden Globes.

. A surgeon general’s report released last month, on the 50th anniversary of the office’s first warning about the dangers of smoking, had little to say about e-cigarettes. Its suggestions for further reducing tobacco use were familiar, including: increase taxes on cigarettes, prohibit indoor smoking, launch media campaigns and reduce the nicotine content of cigarettes.

E-cigarettes, however, could be what we need to knock the U.S. smoking rate from a stubborn 18 percent to the government’s goal of 12 percent by 2020. We should not only tolerate them but encourage their use.

Although critics stress the need for more research, we can say with high confidence that e-cigarettes are far safer than smoking. No tobacco leaves are combusted, so they don’t release the tars and gases that lead to cancer and other smoking-related diseases. Instead, a heating element converts a liquid solution into an aerosol that users exhale as a white plume.

The solution comes in varying concentrations of nicotine — from high (36 mg per milliliter of liquid) to zero — to help people wean themselves off cigarettes, as well as e-cigarettes, and the addictive stimulant in them. But even if people continue using electronic cigarettes with some nicotine, regular exposure has generally benign effects in healthy people, and the FDA has approved the extended use of nicotine gums, patches and lozenges.

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The other main ingredients in e-cigarettes are propylene glycol and glycerin. These are generally regarded as harmless — they’re found in toothpaste, hand sanitizer, asthma inhalers, and many other FDA-approved foods, cosmetics and pharmaceuticals. There are also traces of nitrosamines, known carcinogens, but they are present at levels comparable to the patch and at far lower concentrations than in regular cigarettes — 500- to 1,400-fold lower. Cadmium, lead and nickel may be there, too, but in amounts and forms considered nontoxic.

“Few, if any, chemicals at levels detected in electronic cigarettes raise serious health concerns,” a 2011 study in the Journal of Health Policy determined. “A preponderance of the available evidence shows [e-cigarettes] to be much safer than tobacco cigarettes and comparable in toxicity to conventional nicotine replacement products.” The potential for e-cigarettes to help people quit smoking is encouraging. Yet so far there has been little research on their effectiveness. A study published in the Lancet in November concluded that e-cigarettes, with or without nicotine, were as effective as nicotine patches for helping smokers quit. Granted, patches have had a disappointing record in helping people stay off cigarettes for more than a few months. But there are reasons to think that e-cigarettes would be even more effective outside the laboratory.

Participants in the Lancet study were randomly assigned to nicotine e-cigarettes, patches or placebo e-cigarettes. In the real world, of course, people get to choose. And e-cigarettes have several advantages over patches and gums. For one, they provide a quicker fix, because the pulmonary route is the fastest practical way to deliver nicotine to the brain. They also offer visual, tactile and gestural similiarities to traditional cigarettes.

Reporter Megan McArdle tested the comparison for a Bloomberg Businessweek article this month: “After I’d put it together, I had something surprisingly close to one of the cigarettes I used to smoke. The mentholated tobacco flavor rolled sinuously over my tongue, hit the back of my throat in an unctuously familiar cloud, and rushed through my capillaries, buzzing along my dormant nicotine receptors. The only thing missing was the unpleasant clawing feeling in my chest as my lungs begged me not to pollute them with tar and soot.”

This is where anti-smoking advocates get worried about e-cigarettes being too attractive and encouraging people — especially young people — to become addicted to nicotine and, in some cases, to progress to smoking. The Centers for Disease Control and Prevention stoked concerns with data released in September showing that 1.78 million middle and high school students had tried e-cigarettes and that one in five middle school students who reported trying them said they hadn’t tried traditional cigarettes. “This raises concern that there may be young people for whom e-cigarettes could be an entry point to use of conventional tobacco products, including cigarettes,” the CDC concluded.

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According to that same CDC study, however, an extremely small percentage of teenagers use e-cigarettes regularly — only 2.8 percent of high school students reported using one in the previous 30 days in 2012. And while that number is rising — it was 1.5 percent in 2011 — teenage cigarette smoking rates are at record lows. That might suggest that increased exposure to e-cigarettes isn’t encouraging more people to smoke. But the numbers are so small that it’s too early to make definitive claims about the relationship between teen vaping and smoking.

Yes, we still need research on the long-term health and behavioral impacts of e-cigarettes. Brad Rodu, a pathologist at the University of Louisville, offers an apt analogy between electronic cigarettes and cellphones. When cellphones became popular in the late ’90s, there were no data on their long-term safety. As it turns out, the risk of a brain tumor with prolonged cellphone use is not zero, but it is very small and of uncertain health significance.

In the case of e-cigarettes, Rodu says that “at least a decade of continued use by thousands of users would need to transpire before confident assessments could be conducted.” Were the FDA to ban e-cigarette marketing until then, the promise of vaping would be put on hold. Meanwhile, millions of smokers who might otherwise switch would keep buying tobacco products. “We can’t say that decades of e-cigarette use will be perfectly safe,” Rodu told me, “but for cigarette users, we are sure that smoke is thousands of times worse.”

The FDA should call for reliable, informative labeling and safe manufacturing standards for e-cigarettes. It should also allay concerns about potential gateway use and youth addiction to nicotine by banning the marketing and sale of e-cigarettes to minors. It should not be heavyhanded in restricting marketing and sales to adults.

Instead, promoting electronic cigarettes to smokers should be a public health priority. Given that the direct medical costs of smoking are estimated to be more than $130 billion per year, along with $150 billion annually in productivity losses from premature deaths, getting more smokers to switch would result in significant cost savings — as well as almost half a million lives saved each year.

We should make e-cigarettes accessible to smokers by eschewing hefty taxes, if we tax them at all, and offering free samples and starter kits. Those kits, which contain a battery, a charger and nicotine-liquid cartridges, typically run between $30 and $90. To reduce the hurdle to initiation, any payer of smoking-related costs — health insurers, Veterans Affairs medical centers, companies that offer smoking-cessation programs for their employees, Medicare, Medicaid — should make the starter kits available gratis. Users should have to pay for their own replacement cartridges, but those are much cheaper than cigarette packs.

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Also, we should allow and welcome public vaping in adult environments such as bars, restaurants and workplaces. Vapers would serve as visual prompts for smokers to ask about vaping and, ideally, ditch traditional cigarettes and take up electronic ones instead.

It may be hard for anti-smoking activists to feel at ease with e-cigarettes in light of their view that traditional cigarette makers have long downplayed the health dangers of their product. This perception has generated distrust of anything remotely resembling the act of smoking. It doesn’t help that major tobacco companies are now investing in e-cigarettes.

But if we embrace electronic cigarettes as a way for smokers to either kick their nicotine addictions or, at least, obtain nicotine in a safer way, they could help instigate the wave of smoking cessation that anti-smoking activists — and all of us — are hoping for.

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17 Facts About E-Cigarettes That Might Surprise You

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Jim Nowlan: The argument for allowing e-cigarettes

Chicago Mayor Rahm Emanuel recently pushed through his city council, a prohibition of "smoking" electronic or e-cigarettes in any public spaces that ban smoking of tobacco cigarettes.

Is that a good idea? After all, any incentive to quit smoking real cigarettes strikes me as a good thing. The issue is sure to come before the Illinois Generally Assembly.

Yet as with nearly all public issues, the matter sharply divides those who see e-cigarettes as a cessation of smoking tool versus those who see the use of e-cigarettes as a gateway for youth to the smoking of the real thing.

This past year, Illinois banned sale of e-cigarettes to those younger than 18. Rep. Kathleen Willis, D-Addison, a chief sponsor of the ban, also is looking into state prohibition on advertising of e-cigarettes, though she admits this may be a federal rather than state issue.

In the interests of providing readers complete information (as complete as this space allows), I decided to experiment with e-cigarettes.

Never having smoked before (gad, I must have been a boring kid), I sought reinforcement from a veteran, one-pack-per-day smoker friend.

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I went to the local Casey's to buy a "pack" of e-cigarettes. When I told her of my mission, the cashier in the convenience store gave me her own Njoy-brand pack, saying she had tried them and didn't like them.

"They have no ending, like a real cigarette; you just keep puffing," the pert young woman, a smoker, said. She seems to enjoy some special satisfaction of the final drag on a cigarette.

"They won't help me stop," she declared, nor have they for anyone she knows.

"Smokers I know substitute e-cigarettes when in a bar," my new-found expert said, "but smoke real cigarettes outside."

Undaunted, my own smoker friend and I "lighted up" the e-cigarettes I got for free.

The Njoy cigarette looks like the real thing, but instead of tobacco inside there is a combination of tiny battery, nicotine and water and atomizer. There is even a red light on the end of the "cigarette" that lights up when you puff.

The $8 e-cigarette is good for the equivalent of two packs of the real thing.

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My veteran smoker friend has smoked since 1975 when he was in the Navy. He has tried quitting a dozen times — gum, patch, cold turkey. Nothing has worked for him.

He took a long pull on the e-cigarette, coughed (too long a drag, he said), and out spewed "smoke," apparently in the form of water vapor, though critics say the white vapor is filled with all sorts of dastardly things.

"Tastes like nicotine," friend said. "It is similar to smoking (he added after several more puffs), just not quite as good. It is harsher than a real cigarette, but not as satisfying."

He then said, "But right now, I don't want a cigarette."

Then I tried a puff, and think I inhaled because my lungs came to attention, infused with the nicotine-laced air swirling around the lung nodules.

Who knows, maybe I'm hooked.

The American Lung Association and respiratory groups all condemn e-cigarettes as "starter products" that mimic cigarettes for the young, even coming in candy flavors.

(Are you old enough to remember candy cigarettes — sticks of white sugar with pink ends?)

The 2012 National Youth Tobacco Survey of 25,000 U.S. middle and high school students found that e-cigarette use doubled between 2011 and 2012 to about 10 percent of all youth but that use of real tobacco products apparently fell.

Opponents of e-cigarettes say the vapor contains possibly toxic chemicals, but other sources say the levels were one-thousandth those of real cigarette smoke.

On the other hand, Chicago aldermen who favor e-cigarettes in public places said that, in the one case, the alderman hasn't smoked since November, and that another was using e-cigarettes to help him kick the tobacco habit.

Created in 2003, e-cigarettes need much more study. Indeed, the Federal Drug Administration hasn't yet provided any guidance on the topic.

The key issues for me are the possible cessation of smoking benefits versus the "starter product" argument that they will lead to greater smoking of real tobacco by young people.

This would be a close call for me if I were a state legislator, a kind of toss-up. But there can be no toss-ups in the legislature. Even "not voting" is a vote against a bill, because in the Illinois legislature a bill must pass by a majority "of all those elected.

So, drawing on my civil liberties values, I would vote to allow continued use of e-cigarettes in public places, until evidence might come forward of the product's real harm. Jim Nowlan is a former Illinois legislator and aide to three unindicted governors, he is the lead author of “Illinois Politics: A Citizen’s Guide” (University of Illinois Press, 2010).

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E-Cigarettes: A $1.5 Billion Industry Braces for FDA Regulation

The first time J. Andries Verleur tried an e-cigarette in 2008, he burned his lip and accidentally inhaled the nicotine fluid. “It was one of the worst products I ever tried,” he recalls, “but the idea was amazing.”

Verleur, a heavy smoker, was living in Prague and happened to spot the strange new product in a Vietnamese grocery store. The crude early version obviously didn’t work very well, but Verleur, a serial entrepreneur, immediately realized that if it did work, it could upend the tobacco industry. That was worth looking into: Cigarettes are a global business that generates more than half a trillion dollars every year, according to data from Euromonitor International.

In its simplest form, an e-cigarette is a cartridge filled with a nicotine solution and a battery powering a coil that heats the solution into vapor, which one sucks in and exhales like smoke. Typically, it looks like a regular cigarette, except the tip, embedded with an LED, often glows blue instead of red. The active ingredient in e-cigarettes is the same nicotine found in cigarettes and nicotine patches.

STORY: Fifty Years of Smoking in Two Charts The effects of inhaling nicotine vapor are not totally understood, but there is no evidence to date that it causes cancer. Experts and logic seem to agree that it’s a lot better than setting chopped-up tobacco leaves on fire and inhaling the nicotine along with thousands of combustion byproducts, some of which are definitely carcinogenic. Because cancer is the main drawback of smoking for a lot of people, the delivery of nicotine without lighting a cigarette is very attractive. And because it produces a wispy vapor instead of acrid smoke, an e-cigarette lets you bring your smoking back indoors, where lighting up in an enclosed space is no longer socially, or legally, acceptable.

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STORY: The Strategy Behind CVS's No-Smoking Campaign It all still represents a tiny fraction of what Americans spend on tobacco, but it’s pretty solid for an industry that barely existed five years ago. A projection by Bloomberg Industries shows e-cigarette sales could surpass that of the traditional tobacco product by as early as 2023. Who will dominate the market is a different question, and one that may be answered not by the markets, but by the government.

A primitive, battery-operated “smokeless non-tobacco cigarette” was patented as early as 1963 and described in Popular Mechanics in 1965. Thomas Schelling, a Nobel prize-winning economist who helped start the Institute for the Study of Smoking Behavior and Policy at Harvard University’s Kennedy School in the 1980s, recalls that people in the 1960s were talking about a charcoal-based vaporizer that would heat some sort of nicotine solution. While those early versions might have been safer than a regular cigarette, they were too expensive and cumbersome to become a substitute for a pack of Camels in a country where, as Schelling notes, “you’re never more than 5 or 10 minutes away from a smoke.”

In a way, electronic cigarettes were made possible by cell phones. The drive to make phones smaller and lengthen their battery life led to the development of batteries and equipment small enough to fit in a container the size and shape of a cigarette. There’s some dispute over who invented the modern e-cigarette, but the first commercially marketed device was created by a Chinese pharmacist, Hon Lik, and introduced to the Chinese market as a smoking cessation device in 2004. From there, e-cigarettes made their way to small shops such as that of the Vietnamese grocer who sold Verleur his first one four years later.

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Now doctors say e-cigarettes do help you quit

- and could save millions of lives... so why are petty bureaucrats intent on banning them from public places?

Lighting up the December night sky outside London's O2 Arena are huge video billboards - and at a concert by British rock band Stereophonics, there is one sponsor: E-Lites, the UK's largest electronic cigarette company. Not very rock and roll... or is it? Stands selling the devices do a roaring trade, while the VIP bar has sold out. As the band take to the stage, the green glow of e-cigarettes can be seen amid the flashes of countless mobile phones. Celebrity fans of vaping - the verb used to describe the 'smoking' of e-cigarettes - include Leonardo DiCaprio, Cara Delevingne, Robert Pattinson and Paris Hilton. So it is seen not only as socially acceptable but, whisper it, cool.

The Royal College of Physicians and a number of GPs now back them as a safer alternative to smoking. Small studies suggest they help smokers quit the real thing. Yet legislators have been less than welcoming. In Australia it is difficult to buy e-cigarettes, while the devices have encountered similar problems in Brazil, Mexico and Hong Kong. And last month, New York City banned them in public places. The then Mayor Michael Bloomberg was said to believe public use of e-cigarettes threatened to undermine enforcement of anti-smoking laws.

The Royal College of Physicians and a number of GPs now back them as a safer alternative to smoking. Small studies suggest they help smokers quit the real thing. Yet legislators have been less than welcoming. In Australia it is difficult to buy e-cigarettes, while the devices have encountered similar problems in Brazil, Mexico and Hong Kong. And last month, New York City banned them in public places. The then Mayor Michael Bloomberg was said to believe public use of e-cigarettes threatened to undermine enforcement of anti-smoking laws.

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< £1.3bn GLOBAL SENSATION Unlike tobacco, e-cigarettes can be freely advertised in Britain on TV, billboards and online, and there are an estimated 1.5 million users here. Last year, global sales reached £1.3 billion. E-cigarettes are battery-operated, usually rechargeable devices. As the user sucks on the gadget, an element is activated which heats a replaceable cartridge filled with liquid containing nicotine, turning it into a vapour that can be inhaled. There is no tobacco and no smoke, but a visible vapour is exhaled. Budget brands can be bought on the high street, while sleeker styles can be found at more upmarket stores and dedicated 'e-lounges'. 'Do you want to sit in a bar as someone blows vapour in your face? Or, given that one person dies of tobacco-related disease every five minutes in the UK, do you want to encourage the use of a product that potentially may save the lives of millions of smokers?' The astonishing popularity - there was an 800 per cent increase in 2013 in smokers using e-cigarettes to kick their habit - is agitating the tobacco industry (its sales fell eight per cent last year), pharmaceutical firms that manufacture nicotine-replacement therapies, and medical bodies concerned about safety. The European Union wants the products banned for 'normalising the action of smoking', but some British doctors view e-cigarettes as essential for smokers wanting to cut down or quit. E-cigarettes will be at the centre of one of the hottest health debates this year. Are they a medical or a lifestyle product? Do you want to sit in a bar as someone blows vapour in your face? Do you care that your eight-year-old child can legally buy e-cigarettes when they cannot buy tobacco? Or, given that one person dies of tobacco-related disease every five minutes in the UK, do you want to encourage the use of a product that potentially may save the lives of millions of smokers?

WHAT IS AN ELECTRONIC CIGARETTE?

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E-cigarettes are battery-powered devices with an atomiser and replaceable cartridge. The cartridge contains nicotine in a solution of either propylene glycol, or glycerine and water which can be flavoured. As the user inhales, the battery heats up the liquid inside the cartridge and produces a vapour which delivers a hit of nicotine. Toxins are at trace levels and comparable to nicotine replacement therapies. Whether e-cigarettes with a nicotine solution are as addictive as regular cigarettes is yet not known. WILL I SAVE MONEY? A starter kit (battery, charger and three cartridges) On average you may save 20 per cent compared with real cigarettes. HOW MANY PUFFS IN A CARTRIDGE? One cartridge is the equivalent of up to 25 cigarettes. The battery lasts between two and five hours before it needs recharging. WILL IT HELP ME QUIT? In a New Zealand study, smokers were giveneither e-cigarettes, nicotine patches or nicotine-free e-cigarettes. Six months later, nicotine e-cigarettes had the highest success rate in terms of users quitting altogether, with 7.3 per cent, then patches at 5.8 per cent and the placebo at four per cent.

LIGHTING UP - IN THE OFFICE YOU may already have an opinion without knowing exactly how an e-cigarette works. In fact, in the absence of any significant studies, bodies such as the British Medical Association have erred on the side of caution and deemed them unsafe. Dr Vivienne Nathanson, the BMA's head of science and ethics, says: 'What they do is normalise the concept of smoking when we've all got used to the fact that smoking in public places isn't allowed.' Indeed, current legislation remains confusing. If you want to use an e-cigarette in the office you would be within your rights - the 2006 Health Act only bans smoking in public places. Yet some employers have already barred such devices - for instance, MPs are not allowed to light up an e-cigar (yes, they make these too) in the Commons.

The NHS has taken an upbeat stance: 'Compared with regular cigarettes they are certainly the lesser of two evils,' its website states. 'Smoking e-cigarettes is generally regarded as a safer alternative to smoking for those unable or unwilling to stop using nicotine.' The US Food and Drug Administration found toxins in the vapour include cancer-causing chemicals nitrosamines and formaldehyde, but the NHS says: 'Levels are about one-thousandth of that in cigarette smoke. We cannot be certain that these traces of toxins are harmless, but tests on animals and a small study of 40 smokers are reassuring, providing some evidence that e-cigarettes are well tolerated and only associated with mild adverse effects such as a dry cough.' While the endorsement is not ringing, the NHS is desperate to reduce the nation's love of tobacco which currently costs the NHS £2.7 billion in treatment a year. The taxpayer spent £88.2 million on 'stop smoking' services in 2012 and £63.4 million for cessation aids in 2011-12. Perhaps an unlikely supporter of e-cigarettes is public health charity Action on Smoking and Health (ASH), established by the Royal College of Physicians (RCP). It believes 'there is little evidence of harmful effects from repeated exposure to propylene glycol, the chemical in which nicotine [in e-cigarette cartridges] is suspended'. Arguably the UK's leading champion of e-cigarettes is ASH board member Professor John Britton. He leads the tobacco advisory group for the RCP, and is director of the UK Centre for Tobacco Control Studies at Nottingham University. He says: 'There are ten million smokers alive today who will eventually be killed by smoking. If they had used e-cigarettes, those deaths could be avoided. It's a massive potential public health prize. Successive governments have failed to tackle tobacco smoking, watching as millions die in an entirely preventable epidemic. 'It is vital to do all we can to help people to quit smoking tobacco, and prevent young people from starting to smoke. Given the right controls, e-cigarettes could make a huge contribution to that.'

TOUGHENING UP THE RULES With an estimated five per cent of the NHS budget spent on the treatment of smoking-related illness, Prof Britton argues that investment should be spent on smoking prevention and the education about the risks of nicotine so that moving on to an alternative such as e-cigarettes makes sense, with a view to eradicating smoking completely. He also remains a staunch supporter of the regulation of e-cigarettes in the UK through the Medicines and Healthcare Products Regulatory Agency (MHRA). The problem is, as Prof Britton explains: 'Some e-cigarettes contain a range of pollutants that do not need to be there. The risk may be trivial in relation to smoking, but could still be important if these products are used in the long term. 'So we need to know the solutions are clean, we need to know the devices work and deliver nicotine effectively. Many smokers have said to me e-cigarettes didn't work for them and have resorted to smoking again; this could be because the product didn't deliver enough nicotine. We also need to make sure companies are promoting the health gains as an alternative to tobacco rather than advertising to children or as a lifestyle accessory.' This is exactly the gripe of Cancer Research UK, which is concerned that celebrity endorsements encourage children to use e-cigarettes - at present there is no age restriction on buying them. Alison Cox, Cancer Research UK's head of tobacco policy, says: 'Tobacco causes one in four cancer deaths. Hundreds of children start smoking every day and we don't want the marketing of e-cigarettes to confuse the message that smoking kills. We aren't opposed to them being marketed to adults and hope the effort encourages many smokers to give up.

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Electronic Cigarette - Smoke Without Fire

Asked recently to write about electronic cigarettes, I have to confess that I had never heard of such a thing. Some internet research later and I discovered that electronic cigarettes are very much a quickly growing concern. A Google search revealed there is no smoke without fire as almost six million results just for the phrase "electronic cigarette" were returned.

What is an electronic cigarette? The electronic cigarette has been in existence for almost three years and is a clever device aimed at providing smokers with a healthier option. Apparently also useful in helping to reduce and indeed quit smoking altogether.

Now in a fourth generation, electronic cigarettes have become much more user friendly than earlier versions which perhaps were a little too large to encourage a mass market appeal. The "mini" is the most realistic e cigarette to date with its length of 100mm being the same as a conventional cigarette.

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An electronic cigarette contains a taste of tobacco but none of the harmful substances found in normal cigarettes allowing smokers cravings to be satisfied without inhaling the many dangerous toxins. Is it all smoke and mirrors? Or can this item really be the saviour it wants to be?

A battery, an atomiser and a renewable nicotine chamber allows the smoker to hold and smoke the electronic cigarette just as they would any other cigarette, even creating a "smoke" like vapour and glow at the end as they draw. The nicotine chamber proves very useful as cartridges are available in different strengths, permitting the user to reduce the amount of nicotine they intake until if they wish, can quit completely.

A nicotine cartridge typically lasts the same time as 15 to 20 cigarettes, thus creating a huge saving to normal costs. Standard, medium, low and no nicotine at all are the various cartridge strengths.

A healthier option altogether it seems, though the benefits don't end there. Due to the electronic cigarette not emitting any dangerous substances, toxins or real smoke for that matter, they are perfectly legal to smoke in public. In winter in particular, normal cigarette smokers have to brave the freezing cold and the rain just for a quick smoking break but this alternative will allow them to stay in their offices, restaurants and pubs.

None smokers also will benefit, as their worries about passive smoking are rendered null and void by the electronic cigarette. A much more sociable environment then!

Upon reflection the electronic cigarette is a healthier, cheaper and environmentally friendly alternative to smoking and as the awareness and the market grows they have great potential to successfully replace the harmful cigarettes we have all come to know and many of us have come to dread and fear.

The electronic cigarette really does seems to be a good idea.

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What is the Best Method to Stop Smoking

Expert Author Victor Shallow A question that most smokers who are considering quitting smoking ask is "What is the best method to stop smoking?" There are millions of people who want to stop smoking. The health problems that smoking can cause are well known, but people are not able to quit because of the highly addictive nature of nicotine, which is in tobacco. Common quit smoking aids which replace the nicotine without smoking, include gum, lozenges, and patches. These aids which are referred to as " Nicotine Replacement Therapy Products" do help satisfy the craving for nicotine.

The problem for many is, the habit of smoking is an overall "experience". It's not only the nicotine. Smokers also like the sensation of raising a cigarette to their mouth and inhaling and exhaling the smoke. The act of smoking gets linked to a pleasurable experience like having a smoke with a good cup of coffee, or after a good meal. The "experience" along with the nicotine, make cigarette smoking an extremely difficult habit to break.

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There is a fairly new product on the market that is gaining in popularity. It's called an electronic cigarette and I think it makes a lot of sense as a method to stop smoking. The electronic cigarette is a battery operated cigarette that gives smokers the feeling of smoking a regular cigarette without all the harmful toxins. The electronic cigarette looks and feels very similar to a regular cigarette. It has a chamber that turns pure liquid nicotine into a puff of vapor giving the sense of smoking a regular cigarette, without all the chemicals that are present in regular cigarette smoke. Smokers get the nicotine and the smoking "experience" without all the health risks of cigarette smoking.

Electronic Cigarettes contain nicotine cartridges which are interchangeable and available in different strengths. This allows a person to gradually reduce the amount of nicotine they consume by switching to cartridges with less nicotine content. The cost of electronic cigarettes is much less than regular tobacco products.

Although electronic cigarettes are much healthier than tobacco, nicotine is very addictive. If you're not a smoker, I definitely would not start. If you're an adult who already smokes and you're looking for a way to reduce the amount, or quit, I would recommend looking into e- cigarettes.

Vic Shallow has researched methods to stop smoking and also different brands of electronic cigarettes. For more information please visit [http://www.methodstostopsmoking.info]

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E-Cigarettes: Separating Fiction From Fact

E-Cigarettes: Separating Fiction From Fact Health experts say more research needed into the devices' safety and effectiveness as a quit-smoking tool

By Serena Gordon HealthDay Reporter

FRIDAY, Jan. 3, 2014 (HealthDay News) -- It's the new year, a time when a smokers' thoughts often turn to quitting.

Some people may use that promise of a fresh start to trade their tobacco cigarettes for an electronic cigarette, a device that attempts to mimic the look and feel of a cigarette and often contains nicotine.

Here's what you need to know about e-cigarettes:

What is an e-cigarette?

The U.S. Food and Drug Administration (FDA) describes an e-cigarette as a battery-operated device that turns nicotine, flavorings and other chemicals into a vapor that can be inhaled. The ones that contain nicotine offer varying concentrations of nicotine. Most are designed to look like a tobacco cigarette, but some look like everyday objects, such as pens or USB drives, according to the FDA.

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How does an e-cigarette work?

"Nicotine or flavorings are dissolved into propylene glycol usually, though it's hard to know for sure because they're not regulated," explained smoking cessation expert Dr. Gordon Strauss, founder of QuitGroups and a psychiatrist at Lenox Hill Hospital in New York City. "Then, when heated, you can inhale the vapor."

The process of using an e-cigarette is called "vaping" rather than smoking, according to Hilary Tindle, an assistant professor of medicine and director of the tobacco treatment service at the University of Pittsburgh Medical Center. She said that people who use electronic cigarettes are called "vapers" rather than smokers.

Although many e-cigarettes are designed to look like regular cigarettes, both Tindle and Strauss said they don't exactly replicate the smoking experience, particularly when it comes to the nicotine delivery. Most of the nicotine in e-cigarettes gets into the bloodstream through the soft tissue of your cheeks (buccal mucosa) instead of through your lungs, like it does with a tobacco cigarette.

"Nicotine from a regular cigarette gets to the brain much quicker, which may make them more addictive and satisfying," Strauss said.

Where can e-cigarettes be used?

"People want to use e-cigarettes anywhere they can't smoke," Strauss said. "I sat next to someone on a plane who was using an e-cigarette. He was using it to get nicotine during the flight." But he noted that just where it's OK to use an e-cigarette -- indoors, for instance? -- remains unclear.

Wherever they're used, though, he said it's unlikely that anyone would get more than a miniscule amount of nicotine secondhand from an e-cigarette.

Can an e-cigarette help people quit smoking?

That, too, seems to be an unanswered question. Tindle said that "it's too early to tell definitively that e-cigarettes can help people quit."

A study published in The Lancet in September was the first moderately sized, randomized and controlled trial of the use of e-cigarettes to quit smoking, she said. It compared nicotine-containing e-cigarettes to nicotine patches and to e-cigarettes that simply contained flavorings. The researchers found essentially no differences in the quit rates for the products after six months of use.

"E-cigarettes didn't do worse than the patch, and there were no differences in the adverse events," she said. "I would be happy if it turned out to be a safe and effective alternative for quitting, but we need a few more large trials for safety and efficacy."

Strauss noted that "although we can't say with certainty that e-cigarettes are an effective way to quit, people are using them" for that purpose. "Some people have told me that e-cigarettes are like a godsend," he said.

Former smoker Elizabeth Phillips would agree. She's been smoke-free since July 2012 with the help of e-cigarettes, which she used for about eight months after giving up tobacco cigarettes.

"E-cigarettes allowed me to gradually quit smoking without completely removing myself from the physical actions and social experience associated with smoking," Phillips said. "I consider my e-cigarette experience as a baby step that changed my life."

Are e-cigarettes approved or regulated by the government?

E-cigarettes are not currently regulated in a specific way by the FDA. The agency would like to change this, however, and last April filed a request for the authority to regulate e-cigarettes as a tobacco product.

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Should electronic cigarettes be as freely available as tobacco? Yes

Jean-François Etter, professor The Medicines and Healthcare Products Regulatory Agency has decided to license electronic cigarettes as medicines from 2016. Simon Chapman (doi:10.1136/bmj.f3840) agrees with regulation, seeing e-cigarettes as another way for big tobacco to try to make nicotine addiction socially acceptable again, but Jean-François Etter says restrictions will result in more harm to smokers

At last smokers have a safer alternative to tobacco. The law in most countries allows the presence of nicotine only in tobacco and in drugs (for example, nicotine replacement therapy patches and gum), effectively prohibiting competitors to tobacco and drug companies from entering the drug market. Because drugs that contain nicotine are unattractive and not very effective,1 people addicted to nicotine tend to use tobacco. Arguably, the laws regulating nicotine cause millions of deaths and unjustifiably protect existing nicotine suppliers at the expense of more innovative competitors, who could devise safer products.

However, electronic cigarettes are about to change this. These products are very successful: sales of e-cigarettes in the United States have doubled every year since they were introduced in 2007.2 Harms of regulation

Until recently, e-cigarettes were able to fly under the legislative radar and the sale of nicotine containing e-cigarettes, although not in compliance …

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The Healthy Skeptic: Electronic Cigarettes

The FDA hasn't approved electronic cigarettes and has tried to stop the products from entering the country. But the gadgets have developed a devoted fan base. By Chris Woolston Even in these days of strict indoor clean air laws, you can still legally puff away in movie theaters, restaurants or even on a plane. You just have to use a cigarette that runs on a battery, not tobacco.

Electronic cigarettes — battery-powered devices that deliver a fine spray of nicotine without any flame or smoke — have been sold in this country for about three years now. Some people use them as a way to quit smoking real cigarettes. Unlike gum or patches, the devices mimic the sensation of smoking while providing the nicotine rush. Other people use them to get their cigarette fix in places where smoking is not allowed.

The Food and Drug Administration hasn't approved electronic cigarettes as an aid to quit smoking or for anything else. The agency has tried to stop the products from entering the country, but its authority over e-cigarettes is still being hashed out in courts. Meanwhile, the gadgets have developed a devoted fan base. On message boards and blogs, e-cigarette users have loudly and clearly proclaimed their allegiance to the devices.

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E-cigarettes — sold without age restrictions online, in some bars and clubs, and at the occasional mall kiosk — come with replaceable cartridges containing various levels of nicotine. The regular cartridges for NPRO cigarettes from NJOY, for example, contain 18 milligrams of nicotine, but you can also get a light version with 12 mg., an ultralight version with 6 mg. and even a nicotine-free version. The company says that, for a typical smoker, each cartridge would last about as long as a pack or pack-and-a-half of cigarettes. For comparison, a smoker would get about 20 mg. of nicotine from a single pack of regular cigarettes. Each cartridge also contains water and propylene glycol, a chemical that helps disperse the nicotine. (Propylene glycol also is a key component of fog made by fog machines, should you be curious.)

The cartridges come with a variety of flavors. Users of the No. 7 cigarette from SS Choice, for example, can choose from tobacco, menthol, blueberry, vanilla and other options — as well as a range of colors. The Hydro Imperial from Crown7 comes in white and black.

A starter pack of NPRO cigarettes containing 10 cartridges costs about $80. A starter pack of No. 7 cigarettes with five cartridges containing 16 mg. of nicotine each costs about $70. A starter pack of Hydro Imperial containing two cartridges with 18 mg. of nicotine each costs a little less than $40. All brands offer replacement cartridges of various strengths and flavors.

Claims: The FDA does not allow e-cigarette companies to market the devices as aids to quit smoking. But both Ron MacDonald, president of Crown7, and Jonas Joiner, marketing director of SS Choice, say they know of plenty of ex-smokers who used e-cigarettes to wean themselves off the real thing. (A spokesperson for NJOY declined to comment because the company is currently in litigation with the FDA.) Some users manage to give up nicotine completely, but others just switch from one source of nicotine to another, MacDonald says. "A lot of people continue to use our product instead of regular cigarettes, and they feel better," he says.

The NJOY website says that an e-cigarette provides "all the pleasure and sensation of smoking without all the health, social and economic problems." The SS Choice site says that its cigarette is more convenient and cost-effective than a regular cigarette and doesn't contain "the thousands of additives and chemicals" found in cigarettes. The Crown7 site says that its cigarettes are "the latest way to get a nicotine fix without most of the harmful effects associated with smoking.

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