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There’s a cigarette plugged into the side of my laptop. A year ago this would have sounded silly – to be honest, it still does – but that may have more to do with my reluctance to admit just how hard it is to quit.
I am a failed quitter. The little white tube sticking out of my computer says so, just as much as the half-finished pack of real cigarettes waiting for me in my kitchen.
It’s a remarkable simulation, the e-cigarette. Market researchers call it “fauxthenticity”
– a replica that looks, tastes, sounds and feels like the real thing. It’s still nicotine addiction, though. Just dressed up in better tech. Product manufacturers know this. They make something called a USB “passthrough” e-cigarette, for when you can’t wait however long it might take for the pseudo cigarette’s battery to charge. Passthroughs allow you to smoke while the front of the cigarette is plugged in to your USB, like a digital nicotine didgeridoo.
This, apparently, is the future of smoking.
Electronic cigarettes are nothing new. A “smokeless non-tobacco cigarette” was patented as early as the mid-1960s, but it never went into production. It wasn’t until the last decade or so that new designs started to yield the first generation of viable e-cigarettes. (What’s inside an e-cigarette?)
In 2003 Chinese pharmacist Hon Lik invented an “Electronic Atomization Cigarette”, which resembled a long white cigarette with a black filter attached. It was a battery-operated mechanism that allowed for a liquid nicotine solution to be atomised into a fine mist or vapour (that’s why using them is known as “vaping”), which could then be inhaled.
From the start, it was clear that e-cigarettes held significant commercial potential – particularly as their development coincided with the global banning of tobacco smoking in most public places. By the mid-2000s, e-cigarettes were being exported and sold in volume. That’s when they faced a new challenge: officials started asking if they were safe.
That’s the billion-dollar question. Or, more accurately, $2-billion – which is what the global e-cigarette market was estimated to be worth at the end of 2013. Consumption of e-cigarettes is expected to grow by an additional 40% to 50% in the next year alone, with some projections suggesting sales will surpass those of traditional tobacco cigarettes within the next decade.
It’s been a decade now since the first commercial e-cigarette units went on sale, and there’s still no consensus as to whether or not e-cigarettes are safe.
Last year the World Health Organisation issued a clear statement: “Until such time as a given ENDS [Electronic Nicotine Delivery System] is deemed safe and effective and of acceptable quality by a competent national regulatory body, consumers should be strongly advised not to use any of these products, including electronic cigarettes.” The WHO’s position – echoed by many other national and global health bodies – is that the “safety of [these devices] has not been scientifically demonstrated”, and that the “potential risks they pose for the health of users remain undetermined.”
Early generations of e-cigarettes were marketed as aids to help people quit smoking, but those claims were subsequently removed from the marketing materials following challenges from health agencies like the WHO, which argued that there was no controlled scientific evidence indicating that electronic cigarettes were “a legitimate therapy for smokers trying to quit”.
This left e-cigarettes in a classification limbo somewhere between tobacco products (which are covered by their own legislation) and regulated medicinal products like nicotine replacement therapies (including gum, patches, lozenges and inhalers).
For manufacturers, the distinction was an important one. Tobacco Products Control Acts provide a regulatory framework – like prohibiting the sale of tobacco products to people under 18 – but don’t stipulate performance requirements outside of what is determined to be responsible marketing, distribution and public awareness around tobacco products.
Regulated medicines or drugs, on the other hand, come with a completely different set of conditions – ones that are much stricter, requiring clinical trials to prove that they are safe and effective; and involving potential classification as a scheduled substance (meaning it may only be available on prescription, or from authorised outlets like pharmacies).
E-cigarette importers and distributors argue that they fall under “tobacco products”, not drugs. When the US Food and Drug Administration tried to block imports of e-cigarettes into that country, calling them “unapproved” drug delivery devices – which would have meant registering e-cigarettes as a new drug product, and then going through years of trials and approvals before they could legally be allowed – the e-cigarette companies took the FDA to court, arguing that because their products “used nicotine derived from tobacco” they were only subject to the [more limited] restrictions of tobacco control laws. The FDA eventually conceded.
Other governments and health agencies seem to be following suit. Earlier this year the European Union introduced new rules for e-cigarettes under a broad revision of general tobacco regulations (rather than the medical classification that was originally proposed). These include banning advertising for e-cigarettes, and a requirement for e-cigarette packs to carry graphic health warnings (like regular cigarettes). The new regulations will be implemented in mid-2016.
In South Africa, the status of e-cigarettes remains unclear. A 2012 amendment to the Medicines and Related Substances Act revised the schedules for nicotine – the drug found in many e-cigarettes. In terms of the changes to the Act, nicotine-containing products “intended for human medicinal use as an aid to smoking cessation, or as a substitute for a tobacco product” were listed as schedule 3 substances. S3 substances (or devices that deliver them) should require a doctor’s prescription, and should only be sold at pharmacies.
By mid-2013 – in response to a claim made by a South African distributor, which said that the wording of the Act didn’t cover e-cigarettes, because they weren’t marketed as medical
devices – the Medicines Control Council took the specific step of confirming that the legislation did indeed apply to e-cigarettes. Still, this hasn’t stopped various e-cigarette suppliers from setting up dozens of new e-cigarette and vaping stores in malls across the country.
As e-cigarettes gain acceptance under the umbrella definition of “tobacco” products (they contain no actual tobacco; even the tobacco-flavoured varieties use artificial flavouring), regulatory bodies seem to want to use this classification to impose the same restrictions on vaping as already exist for tobacco smoking.
In cities like Los Angeles and New York, vaping has been banned in public spaces; similar policies were introduced last year in Spain. In Australia, even nicotine-free “vapourisers” have been the subject of lawsuits – because they mimic the form and actions of tobacco products. The message is clear: e-cigarettes aren’t a licence to light up wherever, whenever.
The default classification of e-cigarettes as tobacco products rather than medicines has meant there’s been no real obligation on the part of manufacturers to submit to or participate in extensive clinical trials of their products. This is changing. Not because of any voluntary philanthropy on the part of big business, but, rather, because of the incredible popularity of e-cigarettes. And because tobacco kills nearly six million people each year.
Independent research (studies and trials not funded by the e-cigarette or tobacco companies) is starting to take a closer look at every aspect of electronic “nicotine delivery technologies” – from the chemicals contained in the solvent and the compounds formed during the atomisation process, to how much nicotine is delivered with each puff or if the exhaled vapour contains any second-hand risks, and (after safety, this is the big one) whether or not e-cigarettes actually help people quit smoking.
There are two central themes in the discussion around what this research could tell us. The first, obviously, is the same question we’ve all been asking from the start: are e-cigarettes safe? The second is more complex: are they safer than tobacco cigarettes?
For now, even though there’s no clear-cut evidence of the former and there are no large-scale, long-term studies that conclusively prove the latter, the language of recent medical and scientific publications seems increasingly sympathetic towards the use of e-cigarettes as an alternative to tobacco smoking.
When it comes to health, first prize, of course, is for people to give up smoking completely. Abstinence equals “do no harm”.
But, faced with the prospect of one billion smokers (that’s how many people the WHO says are tobacco smokers, right now), many of whom either can’t or won’t quit, there is growing support for an approach that counsels: “do less harm”, a model that emphasises reduced exposure to toxins rather than reduced consumption of nicotine.
“I see a lot of lung patients,” says clinical technologist Sandri van Staden, who works in the in the field of Pulmonology at the Lung Function Laboratory at 1 Military Hospital in Pretoria. When one of Van Staden’s patients asked her which was safer – tobacco or electronic cigarettes – she, “had to tell him that I didn’t know. That was what prompted me to do [a] study.” In September last year Van Staden, together with four other authors, published the first South African study on e-cigarettes – in this case, evaluating the levels of carboxyhaemoglobin (when carbon monoxide binds with blood) in a small group of tobacco smokers when they switched to smoking e-cigarettes for two weeks.
“Because I’m a lung function technologist I looked at the health benefits it would have for my patients,” Van Staden says, explaining that her study didn’t extend to safety issues like testing the liquid, or other components of the e-cigarette. “Even over a short period of time we saw really incredible results.” After two weeks on e-cigarettes the participants’ blood carbon monoxide levels were significantly reduced, their cotinine levels (nicotine in blood) were decreased, and the oxygen saturation in their blood had increased.
Van Staden says that she is not promoting
e-cigarettes, but believes that current research, including hers, does suggest they may be “a better route [than tobacco cigarettes], if you can afford it” – and, she adds, if users are informed about the provenance of the e-cigarette brands they buy. Van Staden stresses there is
a wide variation in the quality and ingredients of electronic cigarettes, and that not all brands or models will deliver the same effects.
She is hoping that she’ll be able to do more extensive research in the future, exploring other aspects of e-cigarette use over longer periods of time. “Lung function itself doesn’t differ in two weeks,” she says.
Van Staden’s findings – like many of the nascent studies around e-cigarettes – provide hints, guides, clues of what we might discover as the research matures and study samples and systems expand (the South African study followed just 13 participants), but they don’t give us definitive answers yet. Cancer researchers in the US are conducting tests to work out if long-term exposure to e-cigarette vapour produces similar gene behaviours to those caused by exposure to tobacco smoke (early evidence suggests there might be similarities). Biological studies take biological time, and the truth is that for now we just don’t know. Where research may provide faster, more definitive results is in the area of smoking cessation – although, even here, current findings are producing a barrage of mixed messages.
A New Zealand study published last year found that e-cigarettes were “modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches”. Six months later a US study determined that were not associated with a greater rate of quitting, or even reducing [tobacco] cigarette consumption…
As the e-cigarette industry expands – all the Big Tobacco companies have since jumped on the bandwagon, with most already planning or about to launch their own (or buying up an existing smaller) e-cigarette brands – there’s a growing consumer and commercial lobby with a vested interest in, somehow, legitimising the use and marketing of e-cigarettes. Whether or not this is in our best interests is… a little hazy.
Anti-smoking campaigners are concerned e-cigarettes may ultimately do more harm than good. In a report published in the South African Medical Journal the director of South Africa’s National Council Against Smoking, Yussuf Saloojee, called e-cigarettes a “Trojan horse”, saying the practice simply perpetuated people’s existing nicotine addictions, warning that tobacco companies’ “overall goal is to dissuade smokers from quitting, and that e-cigarettes are merely another means to this end.”
This sentiment is repeated in international trend and market surveys, which show that consumers who “would have been in the market for cessation products may now consider e-cigarettes as a viable alternative, or a healthy enough replacement of traditional cigarettes to delay quitting for good for a while longer.”
Addiction specialists and those counselling a “harm reduction” model have a different take on it: e-cigarettes, they suggest, are a “disruptive” technology that have the potential to undermine the control of Big Tobacco; a “gateway out of smoking” that could “further denormalise smoking and normalise safer alternatives.”
If you’re wondering what to do now, here’s the safest alternative – the only safe alternative: quit.
And good luck.
By Nechama Brodie