Are Electronic Cigarettes a Public Good or Health Hazard?

A new case study byJohn Quelchcharts the growing popularity of electronic cigarettes
and how tobacco companies and regulators are responding.

by Michael Blanding
When electronic cigarettes first appeared a little over a decade ago, they were hailed by
many as a godsend: a tool to help smokers quit while mitigating the most harmful
effects of tobacco. "The [e-cigarette] market is producing, at no cost to the taxpayer, an
emerging triumph of public health," one health advocate said.
Consisting of a small barrel-shaped design that mimics an actual cigarette, the devices
vaporize a liquid nicotine solution, which is then inhaled without the tar and carcinogens
found in smoke. Powered by a battery and controlled with a microchip, users can adjust
the amount of nicotine they inhale, gradually weaning themselves off their addiction if
they choose.
THE VALUE PROPOSITION OF E-CIGARETTES IS CLEAR

"The value proposition of e-cigarettes is clear," saysJohn A. Quelch, Charles Edward
Wilson Professor of Business Administration at Harvard Business School. "They provide
the dubious pleasure of nicotine without all the cancer-inducing toxins associated with
tobacco."
Very quickly, however, enthusiasm faded, when some public health advocates began
worrying that the cure was worse than the disease. And this week the Food and Drug
Administration is proposing thefirst federal oversightof the product.
The very fact users could control the amount of nicotine they ingested led to worry that
e-cigarettes would cause smokers to take in more nicotine, rather than less. Even more
worrisome, e-cigarettes could provide a gateway for young people to start smoking
tobacco cigarettes, or even lure ex-smokers back to the habit.
This has created a dilemma for health regulators, says Quelch, interviewed before the
FDA's action. Do they regulate e-cigarettes in order to decrease the number of new
smokers who may pick up the habit, or do they apply a light hand in order to increase
the number of existing smokers who will quit.
"Put crudely," says Quelch, "how many nicotine addicts is it worth the risk of creating to
have one tobacco smoker quit?"

Electronic cigarettes are powered by a battery and microprocessor.
Photo: iStockPhoto
That is one of the many questions Quelch explores in the HBS case, E-Cigarettes:
Marketing Versus Public Health, written with HBS Research Associate Margaret L.
Rodriguez. It examines the consequences of the products as they have become more
popularand as the big tobacco companies have gotten in on the game. Quelch, who
holds a joint appointment at HBS and Harvard School of Public Health, wrote the case
for a new course debuting next year called "Consumers, Corporations, and Public
Health," which will enroll both MBA and MPH students to consider the intersections of
business and health.
"One of the themes in the course is the tension that exists, quite understandably,
between regulators and commercial interests," says Quelch. "Most people are used to
hearing about that in the context of financial regulation, but similar issues apply in other
sectors of the economy including health care."
In the case of electronic cigarettes, existing evidence indicates that they have led to a
net decrease in smoking. Of the 43.8 million smokers in the United States in 2012, 3.5
million converted to e-cigarettes; during the same period only 1.3 million electronic
cigarette smokers converted to tobacco. That means a net decrease of cigarette
smokers of 2.2 million, or 5 percent.
At the same time, 2.8 million nonsmokers converted to electronic smokes. But even that
doesn't tell the whole story, says Quelch, since it leaves out the number of smokers who
would have taken up tobacco if e-cigarettes didn't exist, as well as the number of
smokers who would have quit cold turkey without the availability of electronic products.
"To really determine the public health impact of e-cigarettes requires a lot of
sophisticated market research and analysis," says Quelch.

A SMOKING MARKET

Uncertainty over health data hasn't hurt the product's popularity. In 2013, electronic
cigarettes tripled in sales in the US to approximately $3 billion. (The overall tobacco
retail market in the US is valued at around $100 billion.) Almost 10 percent of high
school students have tried them, according to the Centers for Disease Control, and a
growing percentage of middle school students are joining the list. In 2012, Goldman
Sachs declared electronic cigarettes one of the top 10 disruptive technologies to watch.
Like most disruptive technologies, electronic cigarettes were developed by small
entrepreneurs with brand names like Logic e Cigarettes (founded 2010), Blu (2009), and
NJOY (2006). By 2013, according to the case study, the e-cigarette category featured
more than 200 brands and their growth was threatening sales of tobacco products.
"If I am a tobacco manufacturer seeing my sales cannibalized by e-cigarettes, I have
two choices: develop my own e-cigarette brand or buy an e-cigarette company,"
says Quelch.
Number three tobacco company Lorillard was the first to blink, buying up Blu in 2012 for
$135 million and aggressively pushing them at convenience store counters. "Distribution
of Blu immediately increased by a factor of three," says Quelch. Other top
manufacturers followed suit, acquiring their own brands and using their shelf-space
clout to increase visibility of the alternative products.

CIGARETTE COMPANIES WILL MANAGE THE MARKETING OF E-CIGARETTE
BRANDS TO MAXIMIZE PROFITABILITY FOR THEIR SHAREHOLDERS
The growing sales of electronic cigarettes also caught the attention of regulators. The
products had been completely unregulatedthey could be advertised on TV and sold to
buyers of any age on the Internet. But once the major tobacco brands began acquiring
e-cigarette makers and displaying those products alongside their mainstay cigarettes,
policymakers took particular notice.
Public health advocates and parents alike worried about the variety of flavors, including
cotton candy that might make "vapes" attractive to children. Some states and cities
responded with restrictions on sales and advertising, and, in April, the Financial Times
reported that the World Health Organization will call for e-cigarettes to be regulated just
like tobacco cigarettes. The US Food and Drug Administration, under mounting
pressure to act, offered its own regulatory plan on April 24.
Ironically, if regulation does go forward, it might help the major tobacco companies by
limiting the marketing playbook of the competitors that were cannibalizing sales of their
products.
The top tobacco competitors know how to deal with regulators, says Quelch, "but with
all those entrepreneurs coming out with flavors and advertising, they would no longer be
able to get traction in their business."

TOBACCO COMPANIES TAKE CONTROL

Quelch predicts the big three tobacco companiesAltria, R.J. Reynolds, and Lorillard
will gain control of the e-cigarette market and then under market their electronic
products in order to retain market share for their more profitable tobacco cigarettes.
"Cigarette companies will manage the marketing of e-cigarette brands to maximize
profitability for their shareholders," says Quelch. "Meaning they'll be able to manipulate
prices in order to control the speed with which tobacco users migrate to e-cigarette
brands."
That means that electronic cigarettes, which are now significantly cheaper on a smoke-
per-smoke basis than heavily taxed tobacco competitors, will probably start climbing in
price and eventually become equal to tobacco brands. That could create an even bigger
windfall for tobacco producers. Even if electronic cigs are regulated like regular
cigarettes, they probably won't be taxed like regular cigarettes, since the tax is on
tobacco, not nicotine (and doesn't apply, for example, to nicotine gum or nicotine
patches)and any new taxes are a nonstarter these days in Congress.
By pricing electronic and tobacco cigarettes to sell similarly at retail, the tobacco
companies could reap enormous profits, concludes Quelch, at the same time giving
them cover against criticism by allowing them to point to "healthier alternatives" in their
product portfolios.
When entrepreneurs first created e-cigarettes and marketed them as a way to quit
smoking, they probably didn't intend to eventually pad the bottom line of mainstream big
tobacco companies. But playing out the scenario to the end, that is exactly what may
happenand all in the absence of any definitive data showing whether e-cigarettes are
more or less harmful to public health than tobacco smokes.
By pointing out such dichotomies and unintended consequences, Quelch hopes he can
motivate MBA students to think more deeply about the public health impacts of business
decisions, as well as getting MPH students to think about the business forces that
shape public health. Only then will decisions be made that properly balance the greatest
good of the public with the ability for entrepreneurs to turn a profit



REFERENCE:
http://hbswk.hbs.edu/item/7449.html
Research on e-cigarettes examining health effects:
Regulations due Natalie McGill
With the look and feel of real cigarettes, electronic cigarettes are experiencing a boom
in popularity. But as the products popularity rises, so do the unknowns about its
potential impact on public health.
As scientific studies on e-cigarettes attempt to catch up with their popularity, it remains
to be seen if the products will be a boon to smoking cessation or a setback toward the
goal of cutting out nicotine for good.
E-cigarettes are battery-powered devices that convert nicotine into vapor. The products
are sold over the counter and are not subject to the same regulation as actual
cigarettes. A 2011 survey showed that about 21 percent of smokers had used e-
cigarettes at least once up from about 10 percent of smokers who took the same
Web survey in 2010, according to a Center for Disease Control and Prevention study
published online in February in Nicotine & Tobacco Research. About 7 percent of
smokers who received the same survey in 2010 via postal mail also said they had tried
e-cigarettes at least once.
The Food and Drug Administration announced in 2011 that the agency plans to propose
regulating e-cigarettes as a tobacco product, according to Jennifer Haliski, a public
affairs officer for FDAs Center for Tobacco Products. Any product containing nicotine
from tobacco, unless marketed for therapeutic purposes, is considered a tobacco
product, according to the 2009 court case, Sottera Inc. v. Food and Drug Administration.
However, concrete regulations on e-cigarettes have yet to be issued, as the science is
still catching up.
Further research is needed to assess the potential public health benefits and risks of
electronic cigarettes and other novel tobacco products, Haliski said.
Getting regular smokers to quit is a potential public health benefit of e-cigarettes, said
Maciej Goniewicz, PhD, an assistant professor of oncology at the Roswell Park Cancer
Institutes Division of Cancer Prevention and Population Sciences.
Goniewicz said that so far he sees e-cigarettes being mostly used by regular smokers
rather than first-time smokers as an alternative to smoking cigarettes, offering
another chance to quit after a relapse. Goniewicz is one of five authors of a Nicotine &
Tobacco Research study published online in April 2012 that compared nicotine and
organic compound vapors of 16 e-cigarette brands available in U.S., United Kingdom
and Polish markets. The study found 300 puffs of e-cigarettes labeled as having high
nicotine levels delivered 0.5 to 15.4 milligrams of nicotine considered negligible
compared to toxins in regular cigarettes.
However, Goniewicz said there is limited data about whether what is exhaled from e-
cigarettes contributes to exposure for people besides the user.
We know theres almost nothing there compared to cigarette smoke, Goniewicz
told The Nations Health. But we dont know whats going on after a very long
exposure. We need to wait for the studies.
Regular use of nicotine, which is found in tobacco, is not without its own health effects.
An addictive substance, nicotine use can lead to increased blood pressure and heart
rate as well as nausea, sweating and diarrhea, according to the National Institutes of
Health. E-cigarettes are not the only product to deliver nicotine to users. A variety of
products are used to provide nicotine to users as a tool for smoking cessation, but such
tools are regulated by FDA.
FDA-approved over-the-counter cessation products include nicotine replacement
chewing gum, lozenges and skin patches. In addition, FDA regulates prescription drugs
that block nicotines effects on a smokers brain.
Tim McAfee, MD, MPH, director of CDCs Office on Smoking and Health and an APHA
member, said it is reasonably certain that if someone who smoked a pack a day
switched completely to e-cigarettes it could represent a benefit to health, but there are
still many caveats and buts around that.
One concern is the use of e-cigarettes in businesses or restaurants to skirt clean air
ordinances or indoor smoking bans, McAfee said. Use of e-cigarettes in places with
established indoor smoking laws could be a step backward for public health when it
comes to air quality, as well as a negative for someone who may have otherwise quit
nicotine, he said.
Someone should not have to go in a restaurant and wonder whats coming out of a
plastic device that is completely unregulated, McAfee said. And we know that nicotine
comes out, which is not fair to expose people to in a public space, since nicotine is a
psychoactive substance.
In Washington, D.C., two members of the Council of the District of Columbia are not
waiting for more studies before proposing regulations.
An exhibitor demonstrates an electronic cigarette at a consumer electronics show in Las
Vegas in 2012. While such products are growing in popularity, their health risks are
unclear.
Photo by Bruce Bennett, courtesy Getty Images
Council members Yvette Alexander and David Grosso introduced legislation April 9 to
classify e-cigarettes as regular cigarettes that are already prohibited in indoor areas in
the city.
Alexander, who chairs the Councils Committee on Health, said her council staff told her
that they had seen people using e-cigarettes inside city bars and restaurants. On a
subsequent trip to a convenience store to find one, a man told Alexander he had
searched for the device in a quest to quit smoking, she said.
These e-cigarettes are marketed in one way in that if you want to smoke you can
smoke indoors, Alexander told The Nations Health. You can beat the ban by smoking
these e-cigarettes, thats one marketing tool.
Alexander noted that e-cigarettes are also touted as an alternative for people trying to
quit smoking. However, it is uncertain if they are less addictive than traditional
cigarettes.
Everyone is up in arms that Im trying to ban the e-cigarettes, Alexander said. Im just
trying to ban them as the same way tobacco products are banned indoors. If you want
to purchase them and smoke them in places where you can smoke tobacco products,
thats fine. But we just want to maintain the ban on tobacco products for indoor use.
Another potential public health concern is how the product is marketed toward teens
and young adults. According to CDC, teens who use smokeless tobacco are more likely
than nonusers to smoke cigarettes, which is a trend CDCs McAfee said he does not
want to see replicated with e-cigarettes.
Jennifer Pearson, PhD, MPH, a research investigator at the Schroeder Institute for
Tobacco Research and Policy Studies at the American Legacy Foundation, said that e-
cigarettes are a novelty product for young adults, along the lines of hookah. Pearson is
a co-author of a study on e-cigarette awareness published in the September issue of
APHAs American Journal of Public Health.
Its (seen as) something fun, different you can do when you go out and something you
can do in the clubs because youre not going to get kicked out, Pearson said.
E-cigarettes continue to evolve, with new models in the absence of federal regulation.
Goniewicz said that rather than limit access to the product, he would prefer that
regulations ensure quality and safety and prevent advertising to children.
My point of view is that we still have cigarettes, and this is the main problem,
Goniewicz said.

REFERENCE
http://thenationshealth.aphapublications.org/content/43/5/1.2.full











Electronic cigarettes: Help or hazard?

Harvey B. Simon, M.D., Editor, Harvard Health

Kicking the cigarette habit is one of the best things that smokers can do for themselves.
Nicotine replacement products, prescription medications, and counseling can all help.
What about the newest tobacco substitute, the electronic cigarette? Despite the appeal
of so-called e-cigarettes, we dont know enough about their safety or effectiveness to
give them the green light
.Electronic cigarettes come in a variety of shapes. Some look like cigarettes, pipes, or
cigars, while others are disguised as pens or other more socially acceptable items.
Whatever their shape, they all are built around a battery-operated heating element, a
replaceable cartridge that contains nicotine and other chemicals, and an atomizer that
converts the chemicals into an inhalable vapor
.A study published this spring in the American J ournal of Preventive Medicine
concluded that electronic cigarettes may help smokers quit. Whether they are a safe
way to quit is another questionpreliminary studies from the FDA, New Zealand, and
Greece raise some concerns.
There are three reasons to worry about electronic cigarettes.
First, the dose of nicotine delivered with each puff may vary substantially. An FDA
analysis recorded nicotine doses between 26.8 and 43.2 micrograms per puff. It also
detected nicotine in products labeled as nicotine free.
Second, electronic cigarettes deliver an array of other chemicals, including diethylene
glycol (a highly toxic substance), various nitrosamines (powerful carcinogens found in
tobacco), and at least four other chemicals suspected of being harmful to humans. To
be sure, the dose of these compounds is generally smaller than found in real cigarette
smoke. But it isnt zero.
Third, by simulating the cigarette experience, electronic cigarettes might reactivate the
habit in ex-smokers. They could also be a gateway into tobacco abuse for young people
who are not yet hooked.
REFERENCE
http://www.health.harvard.edu/blog/electronic-cigarettes-help-or-hazard-201109223395




E-cigarette vapor contains nicotine, not other toxins
BY SHEREEN JEGTVIG

(Reuters Health) - People standing near someone using an e-cigarette will be exposed
to nicotine, but not to other chemicals found in tobacco cigarette smoke, according to a
new study.
E-cigarettes, or electronic cigarettes, create a nicotine-rich vapor that can be inhaled, or
'vaped.'
Researchers and regulators have questioned whether e-cigarettes are a smoking
cessation aid or may lure more young people toward smoking, as well as what effects
they have on health.
"There is ongoing public debate whether e-cigarettes should be allowed or prohibited in
public spaces," study co-author Maciej Goniewicz told Reuters Health in an email.
Goniewicz is a cancer researcher in the Department of Health Behavior at the Roswell
Park Cancer Institute in Buffalo, New York.
"E-cigarettes contain variable amounts of nicotine and some traces of toxicants. But
very little is known to what extent non-users can be exposed to nicotine and other
chemicals in situations when they are present in the same room with users of e-
cigarettes," Goniewicz said.
He and his colleagues conducted two studies of secondhand exposure to e-cigarette
vapors in a laboratory. Their results were published in Nicotine and Tobacco Research.
In the first study, the researchers used an electronic smoking machine to generate
vapor in an enclosed space. They measured the amount of nicotine as well as carbon
monoxide and other potentially harmful gases and particles in the chamber.
The second study included five men who regularly smoked both tobacco cigarettes and
e-cigarettes. Each man entered a room and smoked his usual brand of e-cigarette for
two five-minute intervals over an hour while the researchers measured air quality. The
room was cleaned and ventilated and the experiment was repeated with tobacco
cigarettes.
The researchers measured nicotine levels of 2.5 micrograms per cubic meter of air in
the first study. Nicotine levels from e-cigarettes in the second study were slightly higher
at about 3.3 micrograms per cubic meter. But tobacco cigarette smoking resulted in
nicotine levels ten times higher at almost 32 micrograms per cubic meter.
"The exposure to nicotine is lower when compared to exposure from tobacco smoke.
And we also know that nicotine is relatively safer when compared to other dangerous
toxicants in tobacco smoke," Goniewicz said.
E-cigarettes also produced some particulate matter, but regular cigarettes produced
about seven times more. E-cigarettes didn't change the amount of carbon monoxide or
other gases in the air.
"What we found is that non-users of e-cigarettes might be exposed to nicotine but not to
many toxicants when they are in close proximity to e-cigarette users," said Goniewicz.
"It is currently very hard to predict what would be the health impact of such exposure,"
he added.
He said more research is needed to find out how the current findings correspond to
"real-life" situations, when many people might be using e-cigarettes in a room with
restricted ventilation.
"This is an interesting piece and points in the direction that a number of other studies
are pointing, though it begins to expand the evidence on the potential effects to others,"
Amy Fairchild told Reuters Health in an email.
Fairchild was not involved in the new research, but has studied how e-cigarette use
might impact views on regular cigarettes at the Columbia University Mailman School of
Public Health in New York.
She said the study suggests e-cigarettes are far safer, both in terms of toxins and
nicotine, than tobacco cigarettes when it comes to the health effects on bystanders -
although more research is needed to know for sure.
"In locales considering extending smoking bans to e-cigarettes, I think that these data
weaken the case for more sweeping bans," Fairchild said. "And so this begins to answer
the question about why e-cigarettes are considered better: they reduce risks to both the
user and to the bystander when compared to tobacco cigarettes."
Fairfield said the concern about vaping ultimately revolves around whether e-cigarettes
are going to change broader patterns of smoking at the population level.
"There are potential harms, including promoting continued smoking of cigarettes and
renormalizing cigarette smoking behaviors," Goniewicz said. "Regulatory agencies
around the world will need to make a number of regulatory decisions about product
safety that could have major effects on public health."
Goniewicz has received funding from a drug company that makes medications to aid
smoking cessation. Another study author has received funds from an e-cigarette
manufacturer.
REFERENCE
http://www.reuters.com/article/2014/01/03/us-e-cigarette-idUSBREA020K820140103


























FDA Warns of Health Risks Posed by E-Cigarettes

The Food and Drug Administration (FDA) has joined other health experts to warn
consumers about potential health risks associated with electronic cigarettes.
Also known as "e-cigarettes," electronic cigarettes are battery-operated devices
designed to look like and to be used in the same manner as conventional cigarettes.
Sold online and in many shopping malls, the devices generally contain cartridges filled
with nicotine, flavor, and other chemicals. They turn nicotine, which is highly addictive,
and other chemicals into a vapor that is inhaled by the user.
The FDA is concerned about the safety of these products and how they are marketed
to the public, says Margaret A. Hamburg, M.D., commissioner of food and drugs.
The agency is concerned that
e-cigarettes can increase nicotine addiction among young people and may lead kids
to try other tobacco products, including conventional cigarettes, which are known to
cause disease and lead to premature death
the products may contain ingredients that are known to be toxic to humans
because clinical studies about the safety and efficacy of these products for their
intended use have not been submitted to FDA, consumers currently have no way of
knowing 1) whether e-cigarettes are safe for their intended use, or 2) about what
types or concentrations of potentially harmful chemicals or what dose of nicotine they
are inhaling when they use these products.
The potential health risks posed by the use of e-cigarettes were addressed in a July 22,
2009, phone conference between Joshua M. Sharfstein, M.D., principal deputy
commissioner of food and drugs; Jonathan Winickoff, M.D., chair of the American
Academy of Pediatrics Tobacco Consortium; Jonathan Samet, M.D., director of the
University of Southern California's Institute for Global Health; and Matthew T. McKenna,
M.D., director of the Office on Smoking and Health at the national Centers for Disease
Control and Prevention.
Conference participants stressed the importance of parents being aware of the health
and marketing concerns associated with e-cigarettes. It was stated that parents may
want to tell their children and teenagers that these products are not safe to use.
Of particular concern to parents is that e-cigarettes are sold without any legal age
restrictions, and are available in different flavors (such as chocolate, strawberry and
mint) which may appeal to young people.
In addition, the devices do not contain any health warnings comparable to FDA-
approved nicotine replacement products or conventional cigarettes.
During the phone conference, which was shared with the news media, FDA announced
findings from a laboratory analysis that indicates that electronic cigarettes expose users
to harmful chemical ingredients.
FDAs Division of Pharmaceutical Analysispart of the agency's Center for Drug
Evaluation and Researchanalyzed the ingredients in a small sample of cartridges
from two leading brands of e-cigarette samples.
One sample was found to contain diethylene glycol, a toxic chemical used in antifreeze.
Several other samples were found to contain carcinogens, including nitrosamines.
Agency Actions
FDA has been examining and detaining shipments of e-cigarettes at the border and has
found that the products it has examined thus far meet the definition of a combination
drug device product under the Federal Food, Drug, and Cosmetic Act. The agency has
been challenged regarding its jurisdiction over certain e-cigarettes in a case currently
pending in federal district court.
FDA is planning additional activities to address its concerns about electronic cigarettes.
Meanwhile, health care professionals and consumers may report serious adverse
events or product quality problems with the use of e-cigarettes to FDA through the Med
Watch program, either online or by phone at 1-800-FDA-1088.

REFERENCE
http://www.fda.gov/forconsumers/consumerupdates/ucm173401.htm



Are Electronic Cigarettes A Safe Alternative For Smokers?


KNUTSFORD, UNITED KINGDOM - JULY 05: In this photo illustration a woman
smokes an electronic cigarette on July 5, 2012 in Knutsford, United Kingdom. Electronic
cigarettes are the latest health device for smokers hoping to quit nicotine addiction.
Earlier today a major security operation took place in Staffordshire, England, after a
passenger on a coach used an electronic cigarette which was mistaken for something
more sinister and a full scale security alert was instigated. The 48 passengers were
later allowed to carry on with their journey. (Image credit: Getty Images via @daylife)
Electronic cigarettes have recently been marketed and promoted as a safe alternative
to traditional tobacco smoking, but based on recent research, this popular and growing
trend could be just as harmful to your lungs and overall health. It is estimated that nearly
700,000 people currently use these electronic pens in order to quit smoking.
Electronic cigarettes deliver nicotine through a vapor as opposed to smoke. Although no
combustion is involved, the nicotine is still derived from tobacco. This method of delivery
has been thought to be potentially less harmful than smoking tobacco. The devices are
imported from China and their nicotine content is currently not regulated prior to sale or
distribution.
A study presented at the European Respiratory Societys annual meeting in
Vienna in February, 2012 demonstrated an abrupt increase in airway resistance leading
to a lower level of oxygen in the bloodstream in electronic cigarette users. This could
have dangerous effects on people with coronary artery disease who have obstructing
plaques in their coronary arteries. In their small study, the Athens researchers studied
the effects of the electronic cigarettes on 8 people who never smoked, along with 24
smokers-11 with normal lung function and 13 participants with asthma or chronic
obstructive pulmonary disease (COPD). The study participants all used an electronic
cigarette for 10 minutes. Researchers then conducted measurements of airway
resistance and lung function. All participants had a sudden increase in airway resistance
which lasted about 10 minutes. Interestingly, the increase was more noticeable in
smokers than non smokers, although the effect seen in people with COPD was less
immediate in nature. The researchers stated that it was unclear whether this increase in
resistance had any potential long term effects.
The European Respiratory Society (ERS) smoking cessation guidelines do not currently
recommend the use of such electronic products. A number of physicians in the ERS
note that a number of brands of e- cigarettes contain high levels of nicotine which is
highly addictive, and also linked to development of lung cancer.
According to Dr. Klaus Lessnau, a pulmonary and critical care specialist at Lenox Hill
Hospital in New York City, tobacco cigarettes are the leading preventable cause of
death and disease in the US. He went on to state that although electronic cigarettes
cannot be recommended to improve lung health, there is certainly some degree of harm
reduction compared to regular cigarette use.
Dr. Lessnau explained that there are no major studies to date, but he believed that the
impact on lung cancer will be substantial. He explained that regular tobacco products
produce more than 1,000 toxic substances, many of them tar relatedwhereas,
electronic cigarettes do not. He believes that cardiovascular disease including
myocardial infarction (heart attack) and stroke may not see any major impact, since
there is a connection with nicotine. Although there are no major studies to date, Dr.
Lessnau said that it is very conceivable that lung cancer will be decreased.
In reality, limited conclusions can be drawn from the preliminary findings of the small
study presented in this article. However, data from this study does add to growing
evidence of the harmful effects of e-cigarettes. Well-established methods that can help
you quit smoking such as nicotine gum, patches, and inhalers are known as nicotine
replacement therapy (NRT), and are an advisable alternative to electronic cigarettes.
Regulating the nicotine content of these electronic cigarettes is the next priority, along
with their safety and quality.
REFERENCE
http://www.forbes.com/sites/robertglatter/2012/10/30/are-electronic-cigarettes-a-safe-
alternative-for-smokers/

Smoking Cessation Health Center
E-Cigarettes 101
By R. Morgan Griffin
Electronic cigarettes: Are they safer than tobacco? Or are they a high-tech way to hook
a new generation on a bad nicotine habit?
Nobody knows yet.
Research into the effects of e-cigarettes lags behind their popularity. But ready or not,
the era of e-cigarettes is here. Its a booming, billion-dollar industry -- on track to outsell
tobacco products within a decade. The number of teens and tweens using these
products doubled between 2011 and 2012.
The time to get informed about these products is now.
How E-Cigarettes Work
They look like the real thing. The end glows as you inhale. As you exhale, you puff out a
cloud of what looks like smoke. It's vapor, similar to the fog you might see at rock
shows, says M. Brad Drummond, MD. He's an assistant professor of medicine at Johns
Hopkins University School of Medicine.
All e-cigarettes work basically the same way. Inside, there's a battery, a heating
element, and a cartridge that holds nicotine and other liquids and flavorings. Features
and costs vary. Some are disposable. Others have a rechargeable battery and refillable
cartridges.
Using an e-cigarette is called "vaping."
Are They Safe?
The nicotine inside the cartridges is addictive. When you stop using it, you can get
withdrawal symptoms including feeling irritable, depressed, restless and anxious. It can
be dangerous for people withheart problems. It may also harm your arteries over time.
So far, evidence suggests that e-cigarettes may be safer than regular cigarettes. The
biggest danger from tobacco is the smoke, and e-cigarettes don't burn. Tests show the
levels of dangerous chemicals they give off are a fraction of what you'd get from a real
cigarette. But what's in them can vary.
"E-cigarettes may be less harmful than cigarettes," Drummond says. "But we still don't
know enough about their long-term risks or the effects of secondhand exposure."
Pro and Con
E-cigarettes have triggered a fierce debate among health experts who share the same
goal -- reducing the disease and death caused by tobacco. But they disagree about
whether e-cigarettes make the problem better or worse.
Opponents say that because nicotine is addictive, e-cigarettes could be a "gateway
drug," leading nonsmokers and kids to use tobacco. They also worry that manufacturers
-- with huge advertising budgets and celebrity endorsements -- could
make smoking popular again. That would roll back decades of progress in getting
people to quit or never start smoking.
Others look at possible benefits for smokers. "Obviously, it would be best if smokers
could quit completely," says Michael Siegel, MD, MPH, a professor at Boston
University's School of Public Health. "But if that's not possible, I think they'd be a lot
better off with e-cigarettes. They're a safer alternative."
Siegel compares replacing tobacco with e-cigarettes to heroin users switching to the
painkiller methadone. The replacement may have its own risks, but it's safer.
Some supporters believe that e-cigarettes could help people quit, just like nicotine gum.
Research hasn't shown that yet, though.

REFERENCE
http://www.webmd.com/smoking-cessation/features/electronic-cigarettes















E-cigarettes: miracle or health risk?

More than two million people in the UK get their nicotine hit via electronic cigarettes. But
as 'vaping' replaces smoking and is enthusiastically marketed by the beleaguered
tobacco giants no one is yet sure how safe it actually is



A customer at the Vape Lab in Shoreditch, London, samples the wares. Photograph:
Sean Smith for the Guardian
In 1963, a young Korean war veteran and committed 40-a-day smoker called Herbert A
Gilbert from Beaver Falls, Pennsylvania, filed a patent for a product he described as a
"smokeless non-tobacco cigarette". It functioned by gently heating a nicotine solution
and producing inhalable steam, thereby "replacing burning tobacco and paper with
heated, moist, flavoured air".
As the health risks of tobacco-smoking slowly began to emerge, Gilbert hopefully touted
his device around the big tobacco and medical supplies companies. Several professed
interest, but at a time when, in Britain alone, some 70% of adult males were regular
smokers none apparently saw enough potential in his oddball invention to put any
money into it.
Half a century on, after a decisive intervention by a Chinese pharmacist called Hon Lik,
whose company Ruyan (literally, "Resembling Smoking") began exporting its version of
the electronic cigarette in the mid-2000s, and perhaps just as important the
widespread outlawing of tobacco smoking in enclosed public spaces in many western
countries, the potential has become clearer.
In 2013, according to a survey by YouGov for the anti-tobacco charityAsh (Action on
Smoking and Health), the number of e-cigarette users in the UK surged to 2.1 million, a
three-fold increase over the previous year. The investment bank Goldman Sachs puts
the products top of a list of "creative destroyers" including big data, 3D printing and
natural gas engines that are likely to turn their markets upside down, and sees annual
global sales of e-cigarettes hitting $10bn within a few years.
For V-Revolution in Covent Garden, which claims to be London's first shop dedicated
exclusively to e-cigarettes, that means business is brisk. Since opening last May, the
store has seen a 90% increase in custom, says assistant manager Elizabeth Playle. It
now sells well over 50 reusable e-cigarettes a day at prices, depending on their size
and voltage, ranging from 25 to 90 each plus many more bottles of e-juice, the
liquid mixture of nicotine, flavourings and dilutants that the devices vapourise. Internet
sales are booming.
"It's really, really taken off," says Playle, as a steady stream of dedicated vapers (as
users are known) file in, try out a new flavour some emulate the taste of traditional
cigarettes, such as Chesterfield, Marlboro Red or Camel; others taste of apple, coffee,
berries, tropical fruit, even pia colada and hand over their 7.99 for a 20ml bottle,
generally enough for the equivalent of around 200 cigarettes.
Playle's French-born assistant, Joelle Tabone ("Vaping is huge in France; every small
town has at least one shop"), explains how they work. These are second-generation e-
cigarettes, a step on from the disposable "cig-a-likes" so called because they closely
resemble a tobacco cigarette which contain the "puff equivalent" of around 30
cigarettes and can be bought over the counter in corner shops and chemists for about
7 each.
Elizabeth Playce and
Joelle Tabone of the V-Revolution e-cigarette shop in Covent Garden, London.
Photograph: Linda Nylind for the Guardian
As you puff, the battery at the far end of the device powers a tiny electronic heating
element, the atomiser, contained in the clear, refillable cartridge (the "clearomizer")
attached to the mouthpiece. The e-liquid in the clearomizer, drawn on to the heating
element by fibre wicks, disappears in a cloud of scented vapour, some of which you
inhale (the rest evaporates).
The e-juice is available in three different nicotine strengths, and more sophisticated
devices also let users adjust their e-cigarette's voltage to vary the potency of the "hit"
they get. The idea, essentially, is that e-cigarettes deliver all the sensations of smoking,
plus the all-important nicotine, without the 70-odd carcinogenic chemicals that tobacco
cigarettes generally deliver as well.
Logically, by far their biggest users are smokers. According to Ash's survey, nearly two-
thirds of e-cigarette users in the UK are current smokers seeking to cut down or give up
altogether, while the remaining third are ex-smokers who have already stopped and are
keen not to restart. Only 0.1% of e-cigarette users are nonsmokers.
That certainly chimes with Playle's experience: the "overwhelming majority" of V-
Revolution's customers are tobacco smokers who want to stop, she says some of
them on their doctors' orders. "I would never promote these as a 'healthy option',
because the only good smoking is no smoking," she says. "But when someone has
been told they must give up, and they come in here and start using these You see
the difference."
So far, so marvellous: on the face of it, e-cigarettes look like a near-miraculous
innovation in tobacco harm reduction. By the World Health Organisation's estimates,
tobacco kills half its users and six million people each year die from the direct and
indirect effects of smoking. But the public health community is deeply divided over e-
cigarettes. "Some people think they're fantastic, the miracle product that is going to stop
people smoking cigarettes," says Anna Gilmore, director of the Tobacco Control
Research Group at the University of Bath and UK Centre for Tobacco and Alcohol
Studies. "Others think they're a potential disaster, because nicotine is an addictive drug
and because e-cigarettes may re-normalise smoking."
As far as the health risk is concerned, it is fair to say, as Gilmore notes, that "e-
cigarettes are certain to be way less harmful than cigarettes. Common sense would
dictate that." But equally, while early tests appear to be at least partially reassuring, e-
cigarettes have simply not been around long enough for there to be any reliable long-
term studies of the risk they might represent.
The World Health Organisation (WHO) calls the devices' safety "illusive",noting that the
chemicals they contain are often not disclosed and have not been properly tested. The
US Federal Centers for Disease Control (CDC) has said there is "enough evidence" to
say that switching to electronic cigarettes would "likely be healthier" than smoking. But
mainly because of the near complete lack of regulatory oversight, and because e-
cigarettes do, after all, contain nicotine, which is far from being a "benign substance",
the CDC will not go so far as to pronounce them safe either.
The British Medical Association (BMA) has also warned it is worried by the lack of peer-
reviewed studies on e-cigarette safety, and public health officials elsewhere have
expressed concerns about the purity of the products' ingredients, the precise dose of
nicotine delivered by different devices and liquids, inaccurate product labelling and an
overall lack of quality control in the manufacturing process. "The real truth," says
Gilmore, "is that we just do not know. We cannot say e-cigarettes are risk-free. We
cannot yet be sure what impact they will have on smoking rates or population health,
whether they'll be the miracle product or not."
Nor is there unanimous agreement among public health experts that e-cigarettes even
help people to give up smoking. WHO has said their efficacy as an aid in giving up
smoking is "yet to be demonstrated", adding that it "strongly advises" consumers not to
use them until national regulatory bodies have declared them both effective and safe.
Similarly, the BMA currently encourages doctors to recommend other nicotine
replacement therapies ahead of e-cigarettes (although it says that for patients who are
unwilling to use nicotine gum or patches, or tried them unsuccessfully, the devices can
be presented as a lower-risk option than smoking tobacco).
Many experts, including Ash's former director, Clive Bates, feel strongly that any risks
associated with e-cigarettes are outweighed by their capacity to dramatically take the
harm out of using nicotine. Others, equally strongly, disagree, arguing that even if e-
cigarettes turn out to be perfectly safe, they risk re-normalising what is now, in most
developed countries, a pariah habit: a "lifestyle product" that is actually a way to get, or
keep, people hooked on the real thing.
UK studies seem to suggest little evidence that e-cigarettes might have this effect. But
in a study of 40,000 young Americans unambiguously entitled E-Cigarettes: Gateway to
Nicotine Addiction for US Teens, the University of California's Center for Tobacco
Research and Education found that using e-cigarettes was likely to increase the
probability of experimenting with traditional cigarettes.
And some more outspoken (and, in the vaping community, much-vilified) opponents of
e-cigarettes such as Martin McKee, professor of European Public Health at the London
School of Hygiene and Tropical Medicine, argue that the high proportion of vapers who
also continue to smoke tobacco means that many are, basically, kidding themselves.
Far from having a major positive impact on public health, the anti camp believes, the
whole e-cigarette phenomenon is really about encouraging "dual use" of e-cigarettes
and tobacco, boosting tobacco companies' profits at a time when sales in the developed
world are falling fast, as well as buying them some much-needed credibility.

E-cigarettes are now becoming big business. Photograph: Sean Smith for the Guardian
And here, things start to get complicated because the world's leading tobacco
companies are busy turning themselves into leading players in the e-cigarette
market. RJ Reynolds, Philip Morris, Japan Tobacco International, Imperial
Tobacco (which sells through Boots) and British American Tobacco (BAT) have all
either already launched e-cigarette lines, or have them in development and are
marketing them in almost exactly the same way as cigarettes used to be in the days
when tobacco advertising was still allowed.
"E-cigarettes are being marketed just like cigarettes were in the past," says Gilmore,
pointing to a TV advertisement for Vype, the e-cigarette brand owned by BAT, which
featured an attractive young couple running through a cityscape before leaping into a
cloud of vapour promising of "pure satisfaction for smokers".
Gilmore says e-cigarettes could be seen as "a godsend for the tobacco industry. With
cigarette companies selling e-cigarettes, there isn't the competition between e-
cigarettes and cigarettes that would likely reduce tobacco-smoking. And just as their last
advertising avenue for tobacco cigarette packets is being closed down, tobacco
companies can advertise e-cigarettes effectively showing lots of pictures of people,
basically, smoking."
Selling e-cigarettes also allows the tobacco companies access to the politicians and
public health bodies who are currently debating how the vaping market should be
regulated, Gilmore points out handily circumventing Article 5.3 of the WHO's
Framework Convention on Tobacco Control, which effectively bars the industry from so
much as talking to governments about public health policy in relation to tobacco. "But
now they are selling e-cigarettes, they can claim to be on the side of the angels," she
says. "It just really muddies the waters."
Governments are still uncertain about how to respond to e-cigarettes. Some, as in the
UK, want to regulate them essentially as medicines as aids to quitting smoking
meaning they will be subject to the same rules on, for example, ingredient quality as
apply to nicotine patches and gum.
The WHO and US seem to favor regulating e-cigarettes in exactly the same way as
tobacco, with strict advertising rules and heavy taxation. The EU looks to be somewhere
in the middle, proposing both controls on ingredients and nicotine strength and
marketing restrictions. Some countries, such as Brazil, have simply banned them
outright, while many local authorities including New York City, Chicago and Los
Angeles, and have outlawed their use in public places, just like tobacco. With passions
running high on both sides, the debate around e-cigarettes seems unlikely to be settled
any time soon.
REFERENCE
http://www.theguardian.com/society/2014/may/05/rise-of-e-cigarettes-miracle-or-health-
risk






The Pros and Cons of E-Cigarettes

You can smoke them virtually anywhere. Many say they will help you quit smoking, a
plus for people with COPD who often struggle with smoking cessation. Others are
skeptical and afraid to try them. The FDA would like to regulate them as medical
products. The e-cigarette industry feels that the FDA has no substantiated reason to do
so. There's a lot of talk going on about e-cigarettes, so before making a decision to use
them, learn the facts about their pros and cons.
What are E-Cigarettes?
Electronic cigarettes, or e-cigarettes for short, are battery-powered devices filled with
liquid nicotine (a highly addictive chemical) that is dissolved in a solution of water
and propylene glycol. Many of them look like real cigarettes, with a white cylindrical
tube, brown filter, and red-glowing tip. Others come in less conspicuous, darker colors.
How Do They Work?
Often termed "vaping," when you take a puff on the end of the e-cigarette tube, a
battery heats up the nicotine, which creates a vapor that is then inhaled into the lungs.
The end result is a sensation of smoke in the mouth and lungs without really smoking.
The Upside to E-Cigarettes
Unlike tobacco products, there are no current laws in effect prohibiting the use of e-
cigarettes in public places. Case in point, I work in a hospital and a fellow nurse smokes
them right there in the nursing station.
Here's what current research says about the positive aspects of this product:
In a study of 40 tobacco-dependent smokers, researchers concluded that smoking e-
cigarettes alleviated the desire to smoke (after abstaining from smoking overnight),
was well-tolerated, and pharmacologically more like a Nicolette inhaler than tobacco.
Another study of 50 smokers who wanted to reduce the health risks associated with
smoking, but not quit completely, concluded that the Eclipse brand of e-cigarettes
dramatically decreased the consumption of cigarettes without causing withdrawal
symptoms. In addition, when participants smoked Eclipse, the nicotine concentrations
in their blood remained fairly stable and their desire to quit altogether remained intact.
However, the study concluded that because the Eclipse increased carbon monoxide
concentrations in the blood, it may not be a safer choice of cigarette. On the other
hand, it caused few, significant adverse events.
In a case study series, the e-cigarette was found to help three study participants --
who all had a documented history of repeated failed attempts at smoking cessation
using professional smoking cessation assistance methods -- quit smoking and remain
abstinent for at least 6 months.
During an online survey conducted in 2010, researchers polled visitors of
websites and discussion forums dedicated to the use of the e-cigarette and smoking
cessation. Of the 3,587 participants, 70% were former smokers, 61% were men, and
the median age was 41 years. On average, participants used the e-cigarette for
approximately 3 months, drew 120 puffs/day, and used 5 cartridges/day. Almost all of
them used cartridges that contained nicotine. Ninety-six percent said that the e-cigarette
helped them quit smoking, while 92% said that it made them smoke less. A majority of
the participants said the e-cigarette helped them fight cravings, cope with withdrawal
symptoms, and avoid relapsing on cigarettes.
The Downside of E-Cigarettes
If you are a savvy consumer, both positive and negative aspects of the the product you
are considering should be scrutinized before you purchase it. The e-cigarette is no
exception. Take a look at what some of the research says about the negative aspects of
the e-cigarette:
A 2010 research paper published in Tobacco Control suggests that the e-cigarette
lacks important regulatory factors, such as essential health warnings, proper labeling,
clear instructions on how to use them, and safe disposal methods. The authors of the
study also found that some of the e-cigarette cartridges leaked, which could cause
toxic exposure to nicotine.
A study published in the December 2011 issue of CHEST found that the e-cigarette
caused acute pulmonary effects after smoking it for only five minutes, although study
authors pointed out that these effects may not be of clinical significance. During the
study, 40 healthy non-smokers (30 experimental/10 control) were asked to smoke the
e-cigarette ad lib for five minutes. The experimental group used the e-cigarette with
the nicotine cartridge in place, while the control group smoked it with the nicotine
cartridge removed.
After five minutes, lung function was assessed using a variety of tests. Results
showed that smoking the device for just five minutes caused an increase in
impedance, peripheral airway flow resistance, and oxidative stress in the lungs of
healthy smokers (smokers who are not diagnosed with lung disease or chronic health
conditions.) They also pointed out that the study only measured results from smoking
the e-cigarette for five minutes -- because the average consumer is likely to smoke
the e-cigarette many times a day, this might increase the risks. However, the authors
suggested that it is possible that if the e-cigarette were used as a short-term bridge to
smoking cessation, the benefits might outweigh the risks.
On their website, the FDA states that states that "E-cigarettes may contain
ingredients that are known to be toxic to humans, and may contain other ingredients
that may not be safe." They also suggest that because e-cigarette manufacturers are
not required to submit clinical study data to them, the public has no way of knowing
"whether e-cigarettes are safe for their intended use, what types or concentrations of
potentially harmful chemicals are found in these products, or how much nicotine they
are inhaling when they use these products." The FDA is also concerned that the
marketing efforts of e-cigarettes may increase addiction to nicotine, especially in
young people, encouraging them to experiment with real tobacco products.
The Best Way To Quit Smoking
How you choose to quit smoking is a matter of personal choice. The best method is the
one that works for you. With this in mind, doing whatever it takes to be successful -- and
safe -- is how many people ultimately approach it.
Consult your health care provider about different stop smoking aids, including nicotine
replacement therapy, quit smoking medications such as Clonidine and Wellbutrin, quit
smoking support groups, and educational materials.
If you decide to try the e-cigarette, be sure to discuss this with your doctor and do your
homework. Understand the pros, cons, and safety concerns, and then make an
informed decision. The most important thing to remember is, no matter how you do it;
you are making the best decision of your life when you finally decide to quit smoking,
especially if you have COPD.
REFERENCE
http://copd.about.com/od/quittingsmoking/a/E-Cigarettes.htm


























Research on E-cigarettes Examining Health Effects
Natalie McGill
Introduction
With the look and feel of real cigarettes, electronic cigarettes are experiencing a boom
in popularity. But as the product's popularity rises, so do the unknowns about its
potential impact on public health.
As scientific studies on e-cigarettes attempt to catch up with their popularity, it remains
to be seen if the products will be a boon to smoking cessation or a setback toward the
goal of cutting out nicotine for good.
E-cigarettes are battery-powered devices that convert nicotine into vapor. The products
are sold over the counter and are not subject to the same regulation as actual
cigarettes. A 2011 survey showed that about 21 percent of smokers had used e-
cigarettes at least once up from about 10 percent of smokers who took the same
Web survey in 2010, according to Center for Disease Control and Prevention study
published online in February in Nicotine & Tobacco Research. About 7 percent of
smokers who received the same survey in 2010 via postal mail also said they had tried
e-cigarettes at least once.
The Food and Drug Administration announced in 2011 that the agency plans to propose
regulating e-cigarettes as a tobacco product, according to Jennifer Haliski, a public
affairs officer for FDA's Center for Tobacco Products. Any product containing nicotine
from tobacco, unless marketed for therapeutic purposes, is considered a tobacco
product, according to the 2009 court case, Sottera Inc. v. Food and Drug Administration.
However, concrete regulations on e-cigarettes have yet to be issued, as the science is
still catching up.
"Further research is needed to assess the potential public health benefits and risks of
electronic cigarettes and other novel tobacco products," Haliski said.
Getting regular smokers to quit is a potential public health benefit of e-cigarettes, said
Maciej Goniewicz, PhD, an assistant professor of oncology at the Roswell Park Cancer
Institute's Division of Cancer Prevention and Population Sciences.
Goniewicz said that so far he sees e-cigarettes being mostly used by regular smokers
rather than first-time smokers as an alternative to smoking cigarettes, offering
another chance to quit after a relapse. Goniewicz is one of five authors of a Nicotine &
Tobacco Research study published online in April 2012 that compared nicotine and
organic compound vapors of 16 e-cigarette brands available in U.S., United Kingdom
and Polish markets. The study found 300 puffs of e-cigarettes labeled as having high
nicotine levels delivered 0.5 to 15.4 milligrams of nicotine considered negligible
compared to toxins in regular cigarettes.
However, Goniewicz said there is limited data about whether what is exhaled from e-
cigarettes contributes to exposure for people besides the user.
"We know there's almost nothing there compared to cigarette smoke," Goniewicz
told The Nation's Health. "But we don't know what's going on after a very long exposure.
We need to wait for the studies."
Regular use of nicotine, which is found in tobacco, is not without its own health effects.
An addictive substance, nicotine use can lead to increased blood pressure and heart
rate as well as nausea, sweating and diarrhea, according to the National Institutes of
Health. E-cigarettes are not the only product to deliver nicotine to users. A variety of
products are used to provide nicotine to users as a tool for smoking cessation, but such
tools are regulated by FDA.
FDA-approved over-the-counter cessation products include nicotine replacement
chewing gum, lozenges and skin patches. In addition, FDA regulates prescription drugs
that block nicotine's effects on a smoker's brain.
Tim McAfee, MD, MPH, director of CDC's Office on Smoking and Health and an APHA
member, said it is reasonably certain that if someone who smoked a pack a day
switched completely to e-cigarettes it could represent a benefit to health, but there are
still many "caveats and 'buts' around that."
One concern is the use of e-cigarettes in businesses or restaurants to skirt clean air
ordinances or indoor smoking bans, McAfee said. Use of e-cigarettes in places with
established indoor smoking laws could be a step backward for public health when it
comes to air quality, as well as a negative for someone who may have otherwise quit
nicotine, he said.
"Someone should not have to go in a restaurant and wonder what's coming out of a
plastic device that is completely unregulated," McAfee said. "And we know that nicotine
comes out, which is not fair to expose people to in a public space, since nicotine is a
psychoactive substance."
In Washington, D.C., two members of the Council of the District of Columbia are not
waiting for more studies before proposing regulations.
Councilmembers Yvette Alexander and David Grosso introduced legislation April 9 to
classify e-cigarettes as regular cigarettes that are already prohibited in indoor areas in
the city.
Alexander, who chairs the Council's Committee on Health, said her council staff told her
that they had seen people using e-cigarettes inside city bars and restaurants. On a
subsequent trip to a convenience store to find one, a man told Alexander he had
searched for the device in a quest to quit smoking, she said.
"These e-cigarettes are marketed in one way in that if you want to smoke you can
smoke indoors," Alexander told The Nation's Health. "You can beat the ban by smoking
these e-cigarettes, that's one marketing tool."
Alexander noted that e-cigarettes are also touted as an alternative for people trying to
quit smoking. However, it is uncertain if they are less addictive than traditional
cigarettes.
"Everyone is up in arms that I'm trying to ban the e-cigarettes," Alexander said. "I'm just
trying to ban them as the same way tobacco products are banned indoors. If you want
to purchase them and smoke them in places where you can smoke tobacco products,
that's fine. But we just want to maintain the ban on tobacco products for indoor use."
Another potential public health concern is how the product is marketed toward teens
and young adults. According to CDC, teens who use smokeless tobacco are more likely
than nonusers to smoke cigarettes, which is a trend CDC's McAfee said he does not
want to see replicated with e-cigarettes.
Jennifer Pearson, PhD, MPH, a research investigator at the Schroeder Institute for
Tobacco Research and Policy Studies at the American Legacy Foundation, said that e-
cigarettes are a novelty product for young adults, along the lines of hookah. Pearson is
a co-author of a study on e-cigarette awareness published in the September issue of
APHA's American Journal of Public Health.
"It's (seen as) something fun, different you can do when you go out and something you
can do in the clubs because you're not going to get kicked out," Pearson said.
E-cigarettes continue to evolve, with new models in the absence of federal regulation.
Goniewicz said that rather than limit access to the product, he would prefer that
regulations ensure quality and safety and prevent advertising to children.
"My point of view is that we still have cigarettes, and this is the main problem,"
Goniewicz said.
REFERENCE
http://www.medscape.com/viewarticle/813587

































Do e-cigarettes help smokers quit?

These battery-powered electronic cigarettes deliver vaporized nicotine without
tobacco, tar, or other chemicals
Consumer Reports magazine: May 2012

More than 45 million Americans smoke cigarettes, the leading preventable cause of
death in the U.S. Unfortunately, some stop-smoking methods, including nicotine gum
and patches, are less effective than previously thought, according to a recent study in
the journal Tobacco Control.
Enter battery-powered electronic cigarettes, which deliver vaporized nicotine without
tobacco, tar, or other chemicals in regular cigarettes. (But nicotine itself has health risks
of its own and is extremely addictive.) Their battery heats a cartridge of liquid nicotine
solution, creating an aerosolized mist that the user puffs, or vapes.
Though e-cigarettes emit no smoke, they deliver an experience like smoking, including
the way theyre held and the LED tip. Last year, 2.5 million Americans tried one. The
cost: up to $100 for a starter kit, which often includes the e-cig unit, two rechargeable
lithium batteries, and five flavor cartridges. (Each cartridge equals roughly one pack of
cigarettes.)
Fans and foes
Proponents of e-cigarettes say theyre more healthful than the conventional type and
that they might help smokers quit tobacco. Some research backs that up. In a study
published last year in the International Journal of Clinical Practice, researchers
interviewed more than 100 e-cigarette users and found that most were former smokers
who had used the devices to help them quit. Theyd tried to stop smoking previously an
average of nine times, and two-thirds had tried a cessation drug approved by the Food
and Drug Administration. A recent review of the available (albeit meager) scientific
evidence on e-cigarettes in the Journal of Public Health Policy concluded that
electronic cigarettes show tremendous promise in the fight against tobacco-related
morbidity and mortality.
Critics say that too little is known about the safety of e-cigarettes, which are
unregulated. Some experts also worry that their availability onlinewhere a user need
only click a box saying he or she is 18could entice children and teens to try them. So
could some of the flavors, such as pia colada and vanilla.
In 2010, the FDA tried to block the sale of some e-cigarette brands, arguing that theyre
marketed as smoking-cessation devices, which the agency regulates. A court
disagreed. Now, some states (including Mississippi, New Jersey, and Utah) and cities
have proposed or enacted bans on the sale or use of e-cigarettes.
Bottom line. Talk to your doctor before trying to quit smoking with e-cigarettes.
Because theyre not regulated, safety is a question and you use them at your own risk.

What users have reported to the FDA
News reports that an electronic cigarette exploded in a Florida man's mouth in February
spurred us to file a Freedom of Information Act request to with the FDA to see what, if
any, adverse-event reports it has received on e-cigarettes since they came on the U.S.
market in 2006. The agency responded in early March with 39 reports logged
through its adverse-event monitoring system. Of them, 31 dealt with negative health
effects; eight were complaints about customer service or positive comments about e-
cigarettes.
Among the most common complaints were headache, dizziness, nausea, sleepiness,
and coughing or other respiratory symptoms. There was only one report of an e-
cigarette exploding and causing burns.
Adverse-event reports don't establish causality, nor can they show whether a person
was using a product as directed. On the other hand, the FDA estimates that it receives
only 1 to 10 percent of all adverse events experienced by the public on products it
regulates. Other people using e-cigarettes might have had symptoms but not reported
them.
Either way, the reports underscore the need for the FDA to find a way to regulate e-
cigarettes, which occupy a sort of regulatory no-mans land between smoking-cessation
devices and tobacco products. The agency told us that it plans to develop regulations
for e-cigarettes, but no proposed rules have yet been issued.

REFERENCE
http://consumerreports.org/cro/magazine/2012/04/do-e-cigarettes-help-smokers-
quit/index.htm










A new risk of electronic cigarettes
Soon-to-be-released study suggests the popular devices may release
carcinogens
Jamie Kopf


On the eve of publication of new research that raises a major safety concern about
electronic cigarettes, eight U.S. senators last week called on the Food and Drug
Administration to take a hard look at the devices and the ways they're evolvingand to
consider the emerging risks as they move to adopt a final rule on electronic cigarettes.
In a letter dated May 8, 2014, the senators referenced a study to be published this
Thursday, May 15, in the journal Nicotine and Tobacco Research. While the study
remains under embargo until then, a New York Times article published last week
highlighted its key findings, namely that certain high-powered e-cigarettesknown as
"tank systems"can reach high enough temperatures that they emit some of the same
carcinogens, including formaldehyde, found in traditional tobacco smoke. That's
significant, since one argument touted by e-cigarette proponents, and frequently cited
on sites that sell e-cigs, is that they don't produce the toxins associated with traditional
cigarette smoking.
Do the FDA's proposed regulations for e-cigarettes go far enough? We don't think
so.
The forthcoming study is expected to show that the carcinogens are released via the
vapor that the user exhalesbasically the e-cigarette equivalent of secondhand smoke.
"It is important that the [FDA] recognize the potential health impacts associated not only
with the direct inhalation of liquid nicotine through e-cigarettes, but also the impacts that
the emitting 'vapor' or 'plume' may have both to the user and any secondhand inhalers,"
the senators wrote.
The letter urged the agency to take the new findings into consideration as it moves to
adopt final rules and regulations on e-cigarettes, which have as yet been
unregulated. Proposed regulations released by the agency in April are open for public
comment until July 8. At the close of last week, the FDA site had already logged more
than 3,400 comments from consumers, industry representatives, health advocates, and
others.
We'll report more on the study when it's released later this week. In the meantime, you
can read the proposed rules and log a commentor peruse the existing commentson
the FDA website. Interested in more information on e-cigarettes in general? Visit
our Guide to E-Cigarettes.

REFERENCE

http://www.consumerreports.org/cro/news/2014/05/a-new-risk-of-electronic-
cigarettes/index.htm


Is big tobacco abandoning smokes for e-cigarettes?
AUTHOR
Becky Freeman
Research Fellow/Lecturer at University of Sydney

All the major global tobacco companies now have a stake in the e-cigarette market.
mangojuicy/Shutterstock
E-cigarettes. For a product barely anyone had heard of five years ago, they now seem
to be on everyones lips. While much has been written about the safety of these
products and their potential to either support or sabotage efforts to reduce smoking
rates, its timely to consider why the global tobacco industry has taken such a keen
interest in buying e-cigarette companies.
Despite e-cigarettes seemingly dominating public and academic debate on tobacco
control, the global e-cigarette market is minuscule compared to traditional tobacco
products. Euro monitor estimates that the global e-cigarette market was worth US$3
billion in 2013.
Compare this to the global tobacco market, one of the most valuable fast moving
consumer goods industries, worth an estimated US$800 billion more than 260 times
the size of the e-cigarette market. This highly profitable tobacco market, outside of
China, is dominated and controlled by just five major players: Japan Tobacco
International, Imperial Tobacco, British American Tobacco, Philip Morris International,
and Altria/Philip Morris USA.
All the major global tobacco companies now have a stake in the e-cigarette market,
with most buying up independent e-cigarette companies.
Philip Morris International, known as PMI, has taken it a step further: in addition to
recently purchasing UK e-cigarette company Nicocigs Ltd, it will be launching
the Marlboro Heat Stick. Unlike e-cigs, which vaporized liquid nicotine, the Heat Stick
takes normal tobacco and heats it to 350 degrees Celsius to create a tobacco vapor.
PMI plans to introduce the Marlboro Heat Stick in test markets in Japan and Italy later
this year. Similar sorts of products were introduced in the 1990s, but failed dismally
when smokers rejected both the taste and lack of smoking satisfaction. PMI appears
hopeful this latest generation of heat technology will be more acceptable to smokers.

PMI will launch the Marlboro Heat Stick in Tokyo and Italy next year. Stefan/Flicker, CC
BY-SA
On the surface, it might look like the tobacco industry is simply buying up these
companies before they become a major threat to its profits. Or even, that it sees a bright
future for e-cigarettes and wants to control the market.
But considering just how much more profitable traditional cigarettes are than e-
cigarettes, and the tobacco industrys long and chequered corporate history, its
important to question what other motivations they might have.
Tobacco advertising on television is nearly universally banned, the tobacco-friendly
states of Indonesia and Zimbabwe being two holdouts. It has been decades since a
tobacco ad appeared on television screens in the United States and United Kingdom.
But e-cigarette marketing is a booming business in both countries with
controversial television ad campaigns and celebrity endorsements.
Using celebrities, sex, glamour, adventure, rebelliousness, youth and beauty to sell
addictive products is very familiar territory for the tobacco industry. These sorts of
campaigns contradict the tobacco industrys pubic relations message that it is only
interested in selling e-cigarettes to adults who are unable to quit smoking.
Add to the fact that PMI can no longer show packs of Marlboro on store shelves or
splash the iconic red Marlboro chevron on Formula One cars, it can promote the US$69
billion Marlboro brand by putting it on the Heat Stick product.
E-cigarette companies use sex and glamour to sell their products.
E-cigarettes could also help the tobacco industry undo the effects of policies that have
seen cigarettes pushed out of social settings that kept people smoking. While smoking
bans are principally about protecting people, especially workers, from secondhand
smoke, they have an additional positive benefit of reducing smoking rates.
Pushing to allow e-cigarette use in pubs and restaurants means there is no need to quit,
because when you cant smoke, simply use an e-cigarette instead. But, dont forget to
keep smoking the real stuff when you can too.
Since acquiring e-cigarette brands, not one tobacco company has stepped out of the
way of tobacco control policy makers working to reduce smoking. The industry has not
raised a white flag and agreed to no longer oppose effective tobacco control policy
reform.
It is business as usual: oppose, lobby and litigate when countries implement laws that
impact on cigarette sales. Which is why the global treaty to reduce tobacco use,
the World Health Organizations Framework Convention on Tobacco Control, is
explicit in banning tobacco industry influence in tobacco control policy. Finding a
fundamental and irreconcilable conflict of interest between the industry and public
health means the industry is not a welcome stakeholder in formulating public health
policy.
E-cigarettes are a potentially useful tool in giving the tobacco industry a seat back at the
policy table. If it can point to e-cigarettes as proof it cares about consumers and is
working to reduce tobacco harms, then perhaps it will no longer be shut out of the
regulatory process. No matter that e-cigarettes are a tiny portion of its total business.
And finally, e-cigarettes are a huge distraction to tobacco control advocates and policy
makers. No doubt the tobacco industry celebrates witnessing the debate
and division among tobacco control colleagues over the utility of e-cigarettes in
reducing the harms of tobacco use. The less attention paid to the deadly US$800 billion
arm of the business the better.
REFERENCE
http://theconversation.com/is-big-tobacco-abandoning-smokes-for-e-cigarettes-28328


Vaping lessons: Which of your products or services can be
reinvented?
Patrick Stroh, Contributing Writer
Jun 23, 2014, 8:27am CDT Updated: Jun 23, 2014, 1:40pm CDT

Image provided by Getty Images (diego_cervo)
Do you know what vaping is? Heres a hint: e-cigarette users are now a $2 billion
market and growing. They also have a ton of options compared to the traditional
tobacco smoker. Regardless of your position on smoking, vaping, or otherwise, this
product reinvention case study can teach us some important lessons.
While I havent tried an e-cigarette, Tri Nguyen, a young entrepreneur out of
the University of Houston, got me up to speed. He and his business partner, Tom
Huynh, operate a rapidly growing company, Zodist. They sell the e-liquid that an e-
cigarette (basically an atomizer with a battery) turns into vapor. So vaping is the term
used to describe smoking an e-cigarette.
Users can significantly adjust what they experience every time they vape. E-liquid, or e-
juice, is a mix of propylene glycol, vegetable glycerin, optional nicotine, and a blend of
flavors. A normal cigarette has 18 milligrams of nicotine. A vaper can adjust that
nicotine from 18 milligrams down to zero making it a nicotine-free e-cigarette.
As Nguyen was explaining this, he discussed part of their value proposition:
Our main goal is to bring high quality juices to the consumer in the form of a
subscription box. As usersreceive their box shipped to them monthly, they are getting
high-quality juices in flavors they enjoy, which in turn should reduce their dependence
on cigarettes. Customers are getting the juices in flavors they love in a convenient way,
and hopefully they won't have to go out and buy a pack of cigs.
Aside from the nicotine adjustments, users also select the flavor they will inhale. There
are thousands of flavors like Red Star Burst, Tobacco, Earl Grey Tea, and Bubblegum.
With so many choices, a user could go broke trying all these flavors to find what they
like.
Zodist solves this problem by creating flavor profiles for their customers. By asking a
few questions, they narrow the selection the customer should best like, then deliver the
e-liquid through a monthly subscription service. Their subscriber base is growing at a
pretty impressive clip 32 percent week over week.
Another interesting component of this product reinvention is the regulatory environment.
Los Angeles recently banned public vaping or at least generated a lot of media
attention. The Food and Drug Administration is trying to regulate this new product and
market, but they dont fully understand it yet. Stay tuned for more to come in this
immature market.
What products in your value proposition could be reinvented? What could change in the
regulatory, technology and economic model?
We can all benefit by reviewing our products and services with an entrepreneurial eye.
You wont know what you can reinvent to create more value for your company and
customers until then.
Patrick Stroh is a principal at Mercury Business Advisors, which provides management
advisory services in business strategy, innovation, and product development. He is also
the author of "Business Strategy: Plan, Execute, Win!" He recently held positions within
UnitedHealth Group, including chief strategy and innovation officer, client experience
officer, president, and SVP of business strategy. Stroh holds an MBA from the University
of St. Thomas.
REFERENCE
http://www.bizjournals.com/stlouis/how-to/growth-strategies/2014/06/vaping-lessons-
reinvent-your-products.html?page=all


E-cigs and regulation what do investment analysts think?
The investment analysts are always interesting on tobacco and e-cigs, and in a usefully
dispassionate follow-the-money kind of way.
Heres a small collection of quotes Ive seen in recent analyst reports mainly as they
relate to regulation of e-cigarettes. I dont see all reports of course so this is necessarily
selective.
For ease of reference, I have highlighted some parts of quotes in red these are my
emphasis. The bold emphasis is in the original.
BNP Paribas has set up its own e-cigarette operation to find out how it works. It notes
low barriers to entry that characterize the existing industry, which it sees as a threat to
the tobacco industry, but sees medicines regulation ending all that and putting most
existing suppliers out of business and leaving the market to the tobacco industry (Sept
2013)
We have started our own e-cigarette brand. Convinced that e-cigarettes are a material
threat to the Tobacco industry in part because barriers to entry are so low, we decided
to test it for real ourselves. Our brand is Electric Dreams, our initial market is the UK,
our objective is discovery.
Barriers to Entry are extremely low. Procuring our own branded products from China to
sell in the UK was both cheap and easy. Setting up a website, and acquiring the means
to sell on-line,
likewise. Marketing costs and retail distribution are the largest barriers, but to those with
a little more capital these are more easily surmounted.
Regulation can change everything: Medical regulation of e-cigs could fundamentally
change the category. We believe many current suppliers would struggle to meet
medical standards, and for the UK they may have to by 2016. Big players with deeper
pockets would survive and prices could rise a hugely preferable outcome for Tobacco.
Euro monitor International: in an online article , tobacco industry analyst Shane
MacGuill notes the dead hand of regulation on e-cigarette growth (and hence health
impact)
A Sober View the Trend to Medicalisation Threatens to Stifle E-cigarette Growth.
Medicalisation risks dampening or reversing e-cigarette growth and therefore becoming
a costly exercise in the art of pleasing no one. Fitch the ratings agency: points out via
Reuters on 11 October 2013 that more regulation will raise barriers to entry and favour
the tobacco industry while limiting the impact of e-cigarettes on cigarette sales:
Further regulation or demand for scientific studies could make it easier for the tobacco
companies to bridge the gap thanks to their deep pockets and experience of dealing
with a highly regulated trading environment. Tougher regulation, as well as providing a
relative advantage to their e-cigarette divisions, would result in
higher prices for e-cigarettes which could also benefit tobacco companies by limiting
their attraction for smokers and slowing the decline in tobacco sales.
Goldman Sachs on the 8 October argues that the European Parliament vote argues
against medicines regulation improves prospects for e-cigarettes.
a win for the burgeoning e-cigarette market, these will not be broadly classified as
medicines, which would have restricted sales
Wells Fargo Securities is positive about e-cigs, but identifies key ingredients in future
success innovation, advertising and buzz. The very things that are suppressed or
rendered bland and unappealing by by regulation (April 2013)
We remain very bullish on the vast potential of e-cigs given the rapid pace of innovation.
[We believe] that the benefits of e-cigs are becoming increasingly apparent to
consumers, helping to drive trial and repeat purchases aided by stepped-up advertising
and a lot of internet buzz
Wells Fargo Securities is among the bulls on e-cigarettes growth and expects this to
cannibalize the cigarette market (a fair proxy for positive health impact).
Disruptive Innovation, Increased Affordability, Perceived Lower Health Risk, and
Convenience Driving E-Cig Trial and Accelerated Conversion Our proprietary,
interactive model predicts the potential volume that will be displaced from conventional
cigs to e-cigs based on a number of factors over the next decade. Based on our
analysis of the combined market in our
Interactive model, we have increased conviction that consumption of e-cigs could
surpass consumption of conventional cigs within the next decade (by 2023).
Wells Fargo Securities does not see all regulation as fatal to growth of the e-cigarette
industry it believes that American deeming regulation (which it believe will be based
on treating the e-cigarettes more like tobacco rather than a medicine) and modest risk-
based taxation would not derail growth, though would create barriers to entry and
consolidation (June 2013).
Deeming Regulation and Taxation of E-Cigs Likely But This Shouldnt Derail the L.T.
Growth Trajectory of the Category Weve long believed the e-cig category will be
regulated, possibly similar to the conventional cig category, and that e-cigs will likely be
taxed, but in a way that better reflects the potential relative risk. Despite this, we still
believe the long term growth trajectory of the category will be robust. Furthermore,
regulation may actually be positive since it ultimately entrenches existing e-cig players
as it increases barriers to entry.
Morgan Stanley sees innovation as the key to e-cigarette sector growth and believes
this will threaten (= headwind in analyst-speak) the cigarette industry (August 2013)
something they think is already happening [note: 50 basis points = 0.5%].
US cigarette category volumes are soft and e-cigs are the likely culprit. When we made
this call in March we took some risk, whereas today it is conventional wisdom. We
believe e-cig growth is reducing 2013 US cigarette consumption by about 50 basis
points.
While surprised by category growth, we believe the ultimate scale of the US e-cigarette
segment will hinge on further improvement in technology/taste. Importantly, E-cigs may
present a real headwind to the existing US cigarette industry business model
Morgan Stanley reports BATs view that the costs of its investments (probably to
approach pharma standard manufacturing for its MHRA licensed products) would mean
it was loss-making. This obviously has implication for e-cig companies that are not
supported by the well-endowed balance sheets of tobacco companies and would find it
hard to bear losses (Sept 2013).
while BAT believes that the current products are generation 1.0 and that there is
room for improvement / growth, it does not believe the category will be significantly
profitable over the next few years given the level of necessary upfront investment.
Citi sees regulation, notably through bans on vaping in public places, as making e-cigs
less attractive and therefore will disrupt the development of this market for quitting or
cutting down;
E-Cigs: Can the Category Move Beyond the Early Adopter? We believe that indoor
smoking restrictions on e-cigs could prove to be disruptive to consumer trial / retention,
as the convenience and freedom of use of e-cigs is one of the key value propositions for
smokers that opt to dual use or switch to e-cigs.
Citi pursues this theme, pointing out that indoor vaping bans will make it harder for
smokers to make the switch to e-cigarettes and this will tend to slow the uptake of e-
cigarettes (June 2013).
several confounding obstacles for switchers that could meaningfully impact adoption
rates 1. No more convenience factor. For consumers that are dual-using the product,
the advantage of e-cigarettes as a substitute is eliminated by indoor smoking rules. 2.
Lower retention rates. For those users who are using e-cigarettes as a switching /
quitting option, they will have a much harder time sticking with the technology, when
they are forced to stand outside with analog cigarette smokers. There is nothing harder
for a quitter (especially early days) than to be around smokers!

In summary , a pretty clear pattern emerges from analyst reports.
* There is enormous potential for e-cigarettes (though there are bulls and bears on the
eventual prospects) and this threatens to disrupt the tobacco industry, challenging
incumbent market shares and creating opportunities and threats for the tobacco firms in
an otherwise mature industry;
* Regulation, especially medicines regulation, will potentially create high barriers to
entry, diminish the appeal, reduce diversity and raise the costs of e-cigarettes;
* Heavy regulation will be benefit the tobacco industry by making it more likely and able
to dominate the e-cig industry, by reducing competition and by making e-cigs less
competitive relative to cigarettes. The presence of the tobacco industry is inevitable and
(in my view as well) desirable for growth of the category, but excessive regulation could
reduce competition and create a narrow tobacco based oligopoly;
* Innovation is key to developing future generations of vapour products that create a
satisfactory alternative to smoking with mass appeal we are at the relatively early
stages of the development of these products. The extent to which regulation supports or
inhibits innovation is therefore critical to the development of e-cigs.
* Indoor vaping bans destroy one of the valuable selling point for e-cigarettes so will
slow the rise of e-cigarettes and reduce switching, meaning more will smoke or relapse
from vaping to smoking.
A final thought from me we cant just assume e-cigs will develop into a large and
profitable market (as some appear to) challenging the dominance of the cigarette in
nicotine delivery look at NRT for example. It will depend tosome extent on the costs
and impact of regulation and how this affects the pace and nature of innovation, and
what it does to the appeal of the products. That suggests key to a pro-health e-cig
market capable of challenging the dominance of cigarettes is:
* to keep regulatory burdens proportional to risk and to a minimum consistent with
health, safety and consumer protection public policy objectives and mindful of
unintended consequences of excessive regulation;
* to encourage innovation by allowing or encouraging frequent changes to products and
responsiveness to revealed consumer preferences;
* to allow consumer-focussed advertising and creation of buzz among adults;
* to make it easy and attractive to smokers to switch by not banning vaping in public
places and by vapers and venue managers finding mutually respectful accommodation.
That is all counter-cultural for tobacco control and public health organisations, but it is
integral to a credible harm reduction strategy and what they should support if they
want to reduce harm.
Disclaimer : investment analysts are not omniscient or always right. Not all reports are
publicly available on the internet so there are some cases where there is no link
provided to the original and therefore no context, disclaimers, disclosures and some
discuss the US market only. So please take these limitations into account and dont
invest any money on the back of these quotes! Having said that, I think a general sense
of how they see this emerges.