Although e-cigarettes are being put forward as a safer alternative that delivers nicotine without carcinogens and assists smokers to quit, I remained concerned that evidence suggests the products are marketed for purchase and use by children. How else can one explain brands featuring flavors like Gooey Butter Cake, Snicker Doodle, Extra Sweet Cotton Candy, Bananalicious, and-the most outrageous-Gummi Bear.
On March 5, 2014, in response to an email request from the American Lung Association, I attended the city council meeting in Long Beach, California-the first time I had attended such a legislative session. Finally, 3 hours into the meeting, after dozens of speakers, including two cranky old men who each hectored the council on a half-dozen issues, I rose to the podium to speak on the topic of the regulation of electronic cigarettes. Given the 3-minute time allotment, my comments were sharply limited. I began and finished by advising the council to regulate e-cigarettes in the same manner that tobacco products are regulated in Long Beach. I told the council that others would seek to convince them that e-cigarettes are a “harm-reduction” product that helps smokers quit and reduces their exposure to carcinogens and other harmful chemicals in tobacco smoke. I urged them not to accept this assertion unquestioningly, reminding them of the past public acceptance of the putative harm-reduction agent, the “lite” cigarette, originated in Long Beach when a young woman raised in the city, Billie Jean King, collaborated with the tobacco industry in the Virginia Slims tennis tournaments and cigarette ad campaigns. The end result of this and similar campaigns was to convince millions of young American women and girls that it was safe to start or continue to smoke “low-tar” cigarettes. Ultimately this deliberate misinformation contributed to the terrible deaths of hundreds of thousands of women. King went on to serve on the Board of Directors of Philip Morris.
I then expressed my opinion that, although the product is being put forward as a safer alternative that delivers nicotine without carcinogens and assists smokers to quit, I remained concerned that evidence suggests the products are marketed for purchase and use by children. How else can one explain brands featuring flavors like Gooey Butter Cake, Snicker Doodle, Extra Sweet Cotton Candy, Bananalicious, and-the most outrageous-Gummi Bear.
Given more time, I would have told them that, in 2012, “more than 1.78 million middle and high school students nationwide had tried e-cigarettes.” Twenty percent of these young people had not previously smoked cigarettes, and there was also substantial double use, with 75% of e-smokers also smoking cigarettes. They already shared such concern. The legislation was introduced by Councilman Dee Andrews, who registered his concern after seeing children “vaping” in Long Beach schoolyards.
At the core of the problem is the fact that, although the FDA’s Center for Tobacco Products has announced that it plans to exert regulatory control over e-cigarettes, it has not yet done so. E-cigarettes remain neither fish nor fowl; not tobacco products, not medical treatments. The onus for protection of the citizenry rests on local governments. Specifically, there are currently 18 unregulated vaping shops in the city of Long Beach, where those curious about the product can gather in a lounge setting to test various types of e-cigarettes and sample the wide variety of flavors and nicotine content that is available to so-called “vapers” before purchase. There are no restrictions on the use of the product in public venues.
In its essence, the e-cigarette consists of a battery-powered heating coil that vaporizes fluid contained in cartridges and delivers the vapor through a mouthpiece for inhalation by the user. Although vaping shop owners told the council that the mist to which vapers and bystanders are exposed contains only water, nicotine, flavorings, corn syrup, propylene glycol, and glycerin, this vapor has not been extensively tested for possible harmful contents or physiologic effects.
Following my brief comment, a number of the members of the local tobacco control community testified, sharing their concerns that vaping should be carefully regulated, lest the gains in tobacco control, particularly in the striking reduction of the number of young smokers, achieved in California during the past 30 years of public health effort be lost to a process of societal normalization of vaping. Failure to act might rapidly result in a whole new generation of children, adolescents, and young adults addicted to nicotine.
Next up for testimony were a long line of vaping shop owners, who pleaded with the council not to regulate vaping like tobacco products. Most stated that they were ex-smokers who had been able to quit smoking themselves using the e-cigarette and who passionately wanted to offer this same benefit to others. They argued that as ex-smokers, the last thing they wanted to do was to be forced out of bars and restaurants to the sidewalk, rejoining the smoking culture, inhaling secondhand cigarette smoke. Although they welcomed regulation, their biggest concern was that the risks of vaping were being exaggerated and that a ban on customers sampling products inside their shops would result in financial harm or even bankruptcy.
They argued that, earlier that day, the Los Angeles City Council had enacted an e-cigarette regulation that exempted vaping lounges from restriction on use of e-cigarettes in indoor venues. One owner submitted a petition signed by more than 600 vapers. This clearly got the attention of the council members, who appeared to pause and count possible vaporized votes in the next city council election. A motion to modify the proposed regulation to allow vaping inside shops narrowly failed when Andrews stood firm. The council ultimately voted unanimously to ban indoor vaping in all commercial indoor locations.
As I walked out of city hall, a voice hailed me and asked me to stop and talk. I was quickly surrounded by very upset vaping shop owners. They accused me of not having researched the subject and of falsely telling the council that their products contained carcinogens and were ineffective in helping people to quit smoking. I assured them that I had been closely following research on e-cigarettes and other purported harm-reduction devices like snus for many years and had recently reviewed the findings of 71 abstracts from a PubMed search on electronic cigarettes. I told them that this research had not convinced me that there was a major risk of harmful substances in e-vapor. I added that although I had not been able to find convincing research on the efficacy of vaping in smoking cessation, based upon the partial efficacy of nicotine replacement drugs to assist smokers to quit, I was optimistic that e-cigarettes might prove to have similar limited effectiveness.
“If you don’t think e-cigarettes contain carcinogens and might help smokers quit, then why are you hurting our businesses by urging tight regulation?” I answered that there was no question in my mind that based upon published data their products were ending up in the hands of millions of children and adolescents. When I asked them where kids were getting the e-cigarettes, all assured me “not us”; they were tightly regulating sales to those over 18 years old. They speculated that kids are “getting the devices from their parents or from the Internet.”
I told them that although I was impressed that most of them appeared to be sincere in their desire to help in harm reduction and I sympathized with their fears of financial ruin, I and many others in public health were concerned that any benefits of vaping would be counteracted by harms associated with re-normalization of tobacco use, dual use, and popularization of vaping among children and adolescents.
I told them that I am an ex-smoker who has spent most of my adult life treating patients with lung cancers caused by cigarettes, unfortunately in most cases unsuccessfully, and that I have worked hard to try to convince young people not to initiate smoking because they often become addicted quickly to nicotine. I told them that I have also spent an enormous amount of time trying to help people quit smoking, again with limited success. I explained how the tobacco control community in the state of California has been enormously successful in reducing the number of young smokers-by half-but that there was a disturbing prospect that a vaping culture was quickly reintroducing powerfully addictive nicotine to a whole new generation, with the risk that many will not remain satisfied with vaping and will move on to more dangerous tobacco products.
A concern arose during the council meeting that I had not previously considered. At one point, the motion to allow vaping in lounges looked like it would pass, as long as the vaping was from cartridges not containing nicotine. Councilwoman Suja Lowenthal asked, “How could this be policed?”
This is an important consideration, since virtually any substance that dissolves might be delivered to the user in vapor form, and bystanders would not be able to determine what they were involuntarily inhaling. A Web search provided more information on this concern. For example, the High Times Vaporizer Pen website advises potential customers that “a plethora of new pen-sized vapes have hit the market-offering cannabis consumers a stealthy, convenient way to get high in almost any location or situation.” It is not clear whether other hard drugs could be vaporized like nicotine, but a quick search of the Internet on “vaping AND cocaine, meth, and opioids” retrieves chatter on a number of sites indicating that hardcore drug users are actively working on such technological solutions.
I will leave the final word to Los Angeles City Councilwoman Nury Martinez, who is quoted as follows in the March 4, 2014 Los Angeles Times.
“We have a right to…choose to breathe clean air. And if this device turns out to be safe, then we can always undo the ordinance. But if this device proves not to be safe, we cannot undo the harm this will create on the public health.”
1. Stanford School of Medicine. Stanford research into the impact of tobacco advertising. Available at: http://tobacco.stanford.edu/tobacco_main/index.php.
2. Centers for Disease Control and Prevention. E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012. Available at: http://www.cdc.gov/media/releases/2013/p0905-ecigarette-use.html.
3. High Times. The High Times vaporizer pen buyer’s guide. Available at: http://www.hightimes.com/read/high-times-vaporizer-pen-buyers-guide.
4. Wieczner J. 10 things e-cigarettes won’t tell you. Market Watch. The Wall Street Journal. Available at: http://www.marketwatch.com/story/10-things-e-cigarettes-wont-tell-you-2013-11-08.
5. Zahniser D, Gerber M. L.A., other cities cracking down on e-cigarettes. Los Angeles Times. Available at: http://www.latimes.com/local/lanow/la-me-ln-la-other-cities-cracking-down-on-ecigarettes-20140304,0,2120927.story#axzz2x5ACJnW2.