Annals of Internal Medicine

Electronic Cigarettes: Aggregate Harm Thaddeus Bartter, MD


lectronic cigarettes (e-cigarettes) are a new and divisive force in the struggle against tobacco-related morbidity and mortality. Tobacco products are the greatest cause of preventable death and disability in the world. The key issue in the debate about e-cigarettes is consideration of their aggregate effect: their role in the tobacco world and their potential to engender far more addiction and disease than “harm reduction.” Comprehensive understanding of these issues requires data coupled with common sense. E-cigarettes involve liquid nicotine (plus additives) and a delivery device that vaporizes the liquid into an inhalable mist. The nicotine in e-cigarettes may or may not come from tobacco. In 2008, the U.S. Food and Drug Administration attempted to classify e-cigarettes as a drug coupled with a drug delivery device, which would place them under its purview. However, the industry sued and won in 2010; e-cigarettes were declared a “tobacco product.” This designation changed the rules for e-cigarettes; although drugs are required to be proven safe (considered “guilty until proven innocent”), tobacco products, paradoxically, are not. The Family Smoking Prevention and Tobacco Control Act represents a more recent attempt by the U.S. Food and Drug Administration to place restrictions on e-cigarettes. The restrictions are weak as proposed and likely to be further weakened through the process of commentary and compromise. In the 50 years since the U.S. Surgeon General brought awareness of the link between tobacco and disease into the public eye, some strides have been made in the fight against cigarettes, the dominant vector of tobacco-related disease. These include denormalization, price barriers, limitations on advertising and access, and bans on flavoring. Limitation of smoking in public places protects nonsmokers and denormalizes smoking. Taxation and making the selling of individual cigarettes illegal raise price barriers that limit access, particularly for children. Television advertising is prohibited. Flavors (apart from menthol) cannot be used. These controls are limited to cigarettes but do not apply to other “tobacco products.” E-cigarettes, designed to mimic cigarettes, are exempt from all of these hardwon controls. Any restrictions on e-cigarettes to date have occurred at the local level. As a result, we see images of glamorous women with sticks in their hands, exhaling clouds of smoke. Single e-cigarettes can be sold, and there are no price barriers boosted by taxation. Flavors, such as watermelon, are available. The basis of the Family Smoking Prevention and Tobacco Control Act is that virtually all tobacco addiction begins before the legal age for purchase. The developing brain is particularly susceptible to nicotine. Greater than 25% of adolescents aged 12 to 17 years

will become addicted at 1 to 5 cigarettes per day (1). The percentage that becomes addicted decreases steadily with increasing age (1, 2). Therefore, the adolescent years are the “golden years” for addiction; young persons are more susceptible and, once addicted, face a lifetime thereof. The aggregate harm from e-cigarettes stems from the addiction of our children. Nicotine is not the primary cause of cigarette-related death and disease, but it is the addictive agent. Youths are the marketing target for e-cigarettes, which represent the new gateway to cigarettes (2, 3). E-cigarette exposure increases the desire to smoke cigarettes, whereas cigarette exposure does not increase the desire for e-cigarettes (4). Despite the denials of the nicotine industry that they target youths in their marketing, common sense applies: An adult smoker trying to transition from cigarettes does not need a bottle of pink-colored, flavored nicotine called Vape Snack with a slice of watermelon pictured on its label. Targeting youth in advertising for e-cigarettes has been effective. In 2011, 72% of male adolescents aged 14 to 16 years were aware of e-cigarettes compared with 58% of adults (5, 6). As a result of the lack of barriers, e-cigarette use among youths is rapidly increasing. E-cigarettes are the fastestgrowing nicotine product; the percentage of high school students using e-cigarettes increased from 1.5% in 2011 to 13.4% in 2014 (7). Proponents of e-cigarettes do not claim a health benefit. Rather, they argue that e-cigarettes are less harmful than cigarettes. It remains important to recall that nicotine is an addictive toxin, originally refined industrially as an insecticide (8). A focus of current study is to determine whether e-cigarettes decrease tobacco use or simply allow maintenance of nicotine levels when cigarettes are not or cannot be used. E-cigarettes contain unknown quantities of substances known to be harmful and others not known to be harmless. Harmful content may be mitigated over time through regulation. Regardless, e-cigarettes will remain accessible and alluring gateway products to nicotine addiction that mimic cigarettes. They threaten the important barriers that have been slowly built to protect against tobacco products. The American Thoracic Society and American College of Physicians have each recommended that e-cigarettes be regulated and treated in every way like cigarettes (9, 10). This applies to taxa-

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This article was published online first at on 12 May 2015. © 2015 American College of Physicians 59

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IN THE BALANCE tion, advertising, nonsmoking areas, and flavoring. I strongly support those recommendations. According to the Centers for Disease Control and Prevention, “tobacco use is a pediatric epidemic” (2). When we consider e-cigarettes, we should not focus on adult smokers who may use e-cigarettes to boost nicotine levels when they cannot use combustibles or who might, alternatively, mitigate years of tobacco-induced injury by replacing cigarettes with e-cigarettes. We should focus on an unregulated, addictive toxin that is widely available and poised to be the dominant gateway to nicotine addiction for the next generation. E-cigarettes have the capacity to disrupt a 50-year fight against the most preventable cause of disease in the world. They threaten to ensure continued morbidity and mortality as young nicotine addicts who start by vaping watermelon-flavored nicotine convert to a lifetime of using “the real thing,” the cigarette. E-cigarettes are vehicles for aggregate harm. E-cigarettes should be treated like the cigarettes that they emulate and regulated as recommended by the American Thoracic Society and American College of Physicians (9, 10). From University of Arkansas for Medical Sciences, Little Rock, Arkansas. Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at / Requests for Single Reprints: Thaddeus Bartter, MD, University of Arkansas for Medical Sciences, 4301 West Markham, Mail Slot 555, Little Rock, AR 72205; e-mail, tbartter

Author contributions are available at Ann Intern Med. 2015;163:59-60. doi:10.7326/M15-0450

E-Cigarettes: Aggregate Harm

References 1. Kandel DB, Chen K. Extent of smoking and nicotine dependence in the United States: 1991–1993. Nicotine Tob Res. 2000;2:263-74. [PMID: 11082827] 2. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General—Executive Summary. 2012. Accessed at www /#Executive Summary on 20 April 2015. 3. Duke JC, Lee YO, Kim AE, Watson KA, Arnold KY, Nonnemaker JM, et al. Exposure to electronic cigarette television advertisements among youth and young adults. Pediatrics. 2014;134:e29-36. [PMID: 24918224] doi:10.1542/peds.2014-0269 4. King AC, Smith LJ, McNamara PJ, Matthews AK, Fridberg DJ. Passive exposure to electronic cigarette (e-cigarette) use increases desire for combustible and e-cigarettes in young adult smokers. Tob Control. 2014. [PMID: 24848637] doi:10.1136/tobaccocontrol-2014051563 5. Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT. Adolescent males' awareness of and willingness to try electronic cigarettes. J Adolesc Health. 2013;52:144-50. [PMID: 23332477] doi: 10.1016/j.jadohealth.2012.09.014 6. King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010 –2011. Nicotine Tob Res. 2013;15:1623-7. [PMID: 23449421] doi:10.1093/ntr/ ntt013 7. Arrazola RA, Singh T, Corey CG, Husten CG, Neff LJ, Apelberg BJ, et al. Tobacco use among middle and high school students—United States, 2011–2014. MMWR Morb Mortal Wkly Rep. 2015;64:381-5. [PMID: 25879896] 8. Centers for Disease Control and Prevention. NICOTINE: Systemic Agent. Accessed at responsecard_29750028.html on 5 March 2015. 9. Leone FT, Douglas IS. The emergence of e-cigarettes: a triumph of wishful thinking over science [Editorial]. Ann Am Thorac Soc. 2014;11:216-9. [PMID: 24575986] doi:10.1513/AnnalsATS.201312 -428ED 10. Crowley RA, for the Health and Public Policy Committee of the American College of Physicians. Electronic nicotine delivery systems: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;162:583-4. [PMID: 25894027] doi:10.7326/M14-2481

60 Annals of Internal Medicine • Vol. 163 No. 1 • 7 July 2015

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Annals of Internal Medicine Author Contributions: Conception and design: T. Bartter.

Analysis and interpretation of the data: T. Bartter. Drafting of the article: T. Bartter.

Annals of Internal Medicine • Vol. 163 No. 1 • 7 July 2015

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Electronic Cigarettes: Aggregate Harm.

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