Nicolas Hansen hates using his e-cigarette in front of people. He’s not flicking ash or blowing secondhand smoke. Still, the very sight of his device — a special-order. stainless steel device from Greece that resembles a pipe — raises questions.
“A lot of people are like, ‘Oh, are you smoking weed?’ ” he recalled recently.
When he used the traditional electronic cigarette, what users call a cig-alike, he didn’t fare much better. That’s because it looks just like a cigarette. A user puffs on one end, triggering a heating system that vaporizes a liquid nicotine solution inside that looks like cigarette smoke when exhaled. If you’re not looking closely, all you see is a smoker. And with that label comes all of its stigma.
But for a smoker looking to quit, the stigma is secondary to finding a way — any way — to stop. When Hansen first started using e-cigarettes nearly two years ago, he had just quit smoking. He didn’t start using them to quit; it was more just something he wanted to try. But he never went back to cigarettes.
“I feel way better now,” said Hansen, 28, of Troy. “I can smell smells, and I can taste food, and I’m not out of breath going upstairs. I think I would have been able to quit without them, but it actually became a bit of a hobby for me.”
Herein lies the great dilemma over the e-cigarette. A decade after e-cigs first hit the market in China, scientists, public health officials and regulatory bodies are still trying to answer whether it is the latest innovative tool in the smoking cessation arsenal or just another way to enjoy nicotine while skirting the nation’s many smoking bans.
The U.S. Food and Drug Administration is trying to extend its tobacco product oversight to include the devices, as well as other novelty tobacco products such as nicotine gels, hookahs, cigars and any future tobacco products not yet on the market. FDA approval would create a boom-bust scenario for e-cigarette manufacturers, who enjoy the lack of regulations but can’t call their product a legitimate smoking cessation tool without them.
E-cigarettes are safer than cigarettes, most experts have concluded. Aside from nicotine, the only other advertised ingredient in the e-cigarette is propylene glycol, an almost odorless liquid generally recognized as safe by the FDA and used to make the replica smoke. It doesn’t contain the more than 4,000 chemicals and tar traditional tobacco cigarettes do.
But safer doesn’t mean safe. And until the FDA conducts a thorough review of its ingredients, intended use and product labeling, the e-cigarette is likely to remain a source of controversy.
“We work with municipalities that are working to set up tobacco-free communities in parks, and some of them are choosing to include e-cigarettes,” said Judy Rightmyer, director of the Capital District Tobacco-Free Coalition. “Mostly, it’s about enforcement. It’s hard to tell if someone is smoking an e-cigarette or a cigarette. But the more it is seen, the more it reinforces smoking as a normal behavior, and that’s why we’re really looking forward to some regulation from the FDA.”
New York City and Chicago have already passed their own regulations. In December, New York City added e-cigarettes to its public smoking ban, and Wednesday, Chicago passed a law banning the smoking of e-cigarettes in public spaces indoors and within 15 feet of a building entrance.
Rightmyer believes these bans have little to do with secondhand vapor issues and are more about social norms.
“They don’t want the product to become a social norm,” she said. “You want to be able to enforce indoor public smoking bans, and if you see a group of people smoking, five of them using e-cigarettes and one smoking a real cigarette, it’s just a nightmare to enforce.”
E-cigarette opponents have other concerns. It’s unclear yet if there is anything harmful about secondhand nicotine vapor. No studies exist to show whether e-cigarettes cause long-term harm. Manufacturers are glamorizing their products as the alternative to going outside to smoke, so people who smoke both e-cigarettes and cigarettes are likely increasing their nicotine intake.
In September, a CDC survey found youth e-cigarette use had more than doubled from 2011 to 2012 — an alarming but not surprising trend, the center concluded, as manufacturers are marketing flavored e-cigarettes like “vivid vanilla” and “cherry crush” and celebrities like Jenny McCarthy and Courtney Love appear in ads for the products.
“The big tobacco companies have all bought up these little e-cigarette manufacturers,” said Rightmyer. “They need to get young people to smoke to be profitable. The studies show that most people who smoke started before they were 18, so the tobacco industry has to get young people addicted to nicotine to get customers buying their products.”
CDC data showed one in five middle school students who starting using e-cigarettes said they had never tried regular cigarettes, inciting the fear e-cigarettes could be used as a gateway to the real thing.
Hansen, who is a member of an online e-cigarette forum, disagrees. He makes his own nicotine liquid and mixes in his own flavors and says he can’t imagine anyone who tries an e-cigarette before a real cigarette would ever choose the latter.
“I would always choose the e-cig,” he said. “And the reason you hear terms like ‘vaping community’ is because a lot of e-cig users are trying to steer away from the term cigarette.”
For some people — like Audrey Silk, of New York City Citizens Lobbying Against Smoker Harassment — the whole controversy has shone a light on the anti-smoking crusaders.
“This attack on e-cigarette proves what we’ve been saying to our conventional smokers for all these years,” she said: “All these bans have nothing to do with protecting anybody else. We’re talking about vapor here. It’s harmless. It’s just a crusade against smoking and anything that looks like smoking. They would have conniptions if somebody held a pencil up to their mouth and it looked like smoking.”
Peggy Keigley and Dr. Thomas Smith look at the other side of the coin. Keigley, director of the Center for Smoking Cessation for Seton Health in Albany, works directly with people trying to quit smoking. Smith, a pulmonologist at Albany Medical Center, works with patients who are already suffering from lung disease and need to quit smoking.
Controversy aside, both have heard from patients who credit the e-cigarette with helping them quit. Both emphasize this is strictly anecdotal evidence; scientific studies have not proven the e-cigarette to be a reputable smoking cessation device.
“I know for me, at the end of the day, the greatest thing that could ever happen to a smoker is to quit,” said Keigley. “I’m a former smoker myself. If there is something out there that is really helping people, I hate to see it get so bashed that it becomes written off.”
Smith has his patients make a chart when they first come to see him. He asks them to list three reasons for smoking at the top — “because I need the nicotine,” “because it’s a habit” and “fidgety factor.” Each time they smoke, they are to mark down the category that best fits the reason why they chose to smoke a cigarette.
“When you wake up in the morning and smoke, it’s for the nicotine, the drug,” he explained. “When you’re having your coffee and light up, that’s habit. When you’re sitting at your computer working and light up right after putting one out without even thinking, that’s the fidgety factor.”
The FDA-approved smoking cessation tools currently on the market address just the first category. Patches, gum, lozenges, nasal spray and oral inhalers all provide the user with a nicotine fix. Chantix, a prescription medication used to quit smoking, simulates the effect of nicotine on a user. Zyban, a prescription medication also used for depression, stems nicotine cravings in an unknown way.
The one element that’s missing, explained Smith, is the hand-to-mouth repetition.
“Where I’m optimistic about e-cigarettes is that they help deal with the hand-mouth habit and the fidgety factor,” he said. “Often, it’s not enough to do nicotine replacement by patch alone because it doesn’t deal with the other issues. You sit down to play cards with your friends at the end of the week and they’re having beers and smokes. That’s where most people stumble. And that’s why I like the e-cigarette.”
As a pulmonologist, Smith plays two roles. He is a doctor who wants to see his patients put only the safest of things in their body. But he is also a crusader in the war on cigarettes, trying to minimize harm to sick patients with extreme addictions.
“Everybody has seen the rows of crosses on the beaches of Normandy,” he said. “More people die every year of tobacco-related death in the U.S. than all of the military ... deaths in World War II. At some point, rigorous principles have got to be set aside for the reality that cigarettes don’t just kill people, they kill a lot of people. I don’t know all the ingredients in the e-cigarette, but I do know I’ve never seen a person die from one.”
Both Smith and Keigley cite stories from their own interactions with smokers desperate to quit that the e-cigarette can be a successful smoking cessation device.
The e-cigarette turns 10 years old this year, but there has yet to be any study on its long-term effects. This is cause for concern, at least for state Department of Health Commissioner Nirav Shah.
“There has been an increase in use of e-cigarettes coincident with the aggressive marketing of the product,” he wrote in a Dec. 16, 2013, letter to the editor in The New York Times. “But there has been no concomitant increase in the incidence of smoking-cessation coincident with the use of e-cigarettes. Much remains unknown.”