Drugs

Are E-Cigarettes the Holy Grail for Hopelessly Addicted Smokers?

I've tried nicotine patches, lozenges and gum, prescription drugs and hypnotherapy, and none of them are anywhere near as effective as e-cigarettes.

Technology, not social stigma, smoking bans or $12-a-pack cigarettes, may finally doom Big Tobacco's market in dealing death to tens of millions. The looming threat to the industry's bottom line is the e-cigarette, a remarkable device that simulates smoking a real cigarette so effectively that life-long smokers can switch without experiencing any cravings or symptoms of withdrawl.

Smokers don't lose any of what those old 1950s ads called “smoking satisfaction,” but they do lose the carbon monoxide, tar and some 4,000 other nasty chemicals found in cigarettes. They also lose the foul odor that stinks up their clothing and their environment, the offensive yellow stains on their teeth, the little ashes that get everywhere and the sheer joy of standing outside in the cold rain getting dirty looks from passersby while they get their fix. Theoretically, one can “smoke” e-cigarettes on airplanes and in movie theaters and restaurants without disturbing others and without creating clouds of the secondhand smoke that can harm others.

Unsurprisingly, the tobacco lobby, along with Big Pharma, which is trying to guard its share of the multi-billion dollar market for nicotine patches and drug therapies to help people quit smoking, has mounted a bruising battle to keep this technology out of the hands of American smokers.

The e-cigarette was invented in China in 2004. It's a cigarette-shaped tube that contains a rechargeable battery, a mini-vaporizer, a small reservoir, sensors and, in most cases, a light on the tip. The sensor notes when you take a drag on the tube and turns on the vaporizer, which more-or-less instantaneously turns the substances in the reservoir into a stream of visible water vapor that mimics the taste and feel of tobacco smoke. The tip glows like the end of a lit cigarette with each drag. It's infused with the taste of tobacco – or tobacco combined with other flavors for those who are into that sort of thing – and nicotine, in various doses (including none at all). The refill cartridges – which look like the butt of the cigarette--give you about the same number of drags as a pack of cigarettes, but cost around $3 each – a bit more than half the national average and a third of what a pack of smokes go for in places like New York City.

Take the word of an addict who has quit dozens of times over more than 20 years – both “cold turkey” and also with the help of nicotine patches, lozenges and gum, one prescription drug specifically for quitting smoking and two antidepressants that are also widely prescribed for that purpose, and hypnotherapy – and has always gone back to cigarettes: the switch from smoking to “vaping” is effortless.

That's because it delivers the same amount of nicotine as patches, lozenges and gum, but in inhaled form, just like a cigarette. Forget about the habit – this smoker hasn't even wanted an ordinary cigarette since getting the e-cigs a few days after Christmas.

Nicotine replacement therapies (NRT) like the patch work by giving you a dose of nicotine – the addictive agent in tobacco – so you don't bite the heads off of your loved ones while getting over the psychological habit of smoking. In theory, e-cigarettes work the opposite way – maintaining the feel of smoking while you gradually reduce the level of nicotine you consume.

The American Association of Public Health Physicians (AAPHP) says it “favors a permissive approach to e-cigarettes because the possibility exists to save the lives of four million of the eight million current adult American smokers who will otherwise die of a tobacco-related illness over the next twenty years. (PDF)”

Conventional cigarettes account for about 80% of nicotine consumption in the United States, but more than 98% of the illness and death. This harm is not caused by the nicotine, but by toxic products of combustion. A cigarette smoker can reduce his or her risk of future tobacco-related death by 98% or better by switching to a low risk smokeless tobacco product. He or she could cut that risk by 99.9% or better by switching to a nicotine-only delivery product like one of the pharmaceutical products or e-cigarettes.

According to the AAPHP, “a smoker can secure almost all the health benefits of quitting if he or she transitions to an e-cigarette,” and, as this addict can attest, “E-cigarettes may be more acceptable to smokers than the currently available pharmaceutical alternatives.”

But while studies have been conducted on NRT – people who use it often relapse, but are nonetheless 50-70 percent more likely to kick the habit permanently – there has been little empirical research into the effects of e-cigarettes. The FDA did a small study (using 18 refill cartridges from foreign manufacturers), two studies were conducted in Europe and e-cig companies claim to have done a number of small private trials. But despite the fact that there isn't anything in e-cigarettes that isn't also found in NRT (except for the agent that makes the vapor visible, which is also used in asthma inhalers), their safety has yet to be demonstrated in any large clinical trials.

It is that uncertainty – and the fact that a handful of e-cigarette vendors make the scientifically unproven claim that their products are a smoking cessation aid (that claim requires FDA approval) – that the tobacco lobby, pharmaceutical companies and leading anti-smoking groups have seized upon in an attempt to keep e-cigs out of the market.

According to media reports, Big Tobacco lobbied not only to have e-cigs banned, but to get major online retailers like Amazon.com and eBay to stop selling them. Lobbyists for the NRT industry and anti-smoking groups have worked hard to ban e-cigs at the state level, and a number of states have introduced legislation to do just that.

On first blush, it appears that the oddest opponents of the e-cigs are the many anti-smoking groups that have come out against them, including the American Lung Association, American Cancer Society, American Heart Association and American Non-Smoker's Rights. It is strange that groups purporting to be “anti-smoking” oppose a less harmful alternative, especially for those who have proven unwilling or unable to quit.

But scratch the surface, and it becomes clear that many anti-smoking groups themselves have a conflict of interest. That conflict arises from the $206 billion tobacco settlement in 1998, which transferred a massive pile of the industry's take to non-profit anti-smoking campaigns.

The campaigns also received a reported $446 million from the Robert Wood Johnson Foundation for “educating” state legislatures about the dangers of tobacco use. The foundation is the largest philanthropic organization devoted exclusively to health issues, and it does a lot of good work. But here again there is at least the appearance of a conflict of interest: the foundation was begun by the founder and CEO of the pharmaceutical giant Johnson & Johnson, with an endowment of 10 million shares of J & J stock in 1968.

Johnson & Johnson's wholly owned subsidiary, the Alza Corporation, makes Nicoderm and Nicoderm CQ – the leading brand of nicotine patches. Its 2006 acquisition of Pfizer added Nicotrol, Nicorette gum and and Commit lozenges to its stable of brands.

In 2009, the FDA took up the cause, finding that e-cigarettes “contained detectable levels of known carcinogens and toxic chemicals to which users could potentially be exposed." But as Michael Siegel, a professor at Boston University's School of Public health noted, “what the FDA did not tell the media or the public, and what the American Lung Association failed to express alarm over, is the fact that nicotine replacement products themselves have been found to have detectable levels of tobacco-specific nitrosamines... chemicals [that] are consistently carcinogenic in laboratory animals and are widely recognized as carcinogens present in tobacco products.” In other words, tobacco is legal, NRT is legal, there's no obvious reason why this new technology shouldn't be as well.

Nonetheless, the FDA ruled that e-cigarettes were “medical devices,” meaning that an exhaustive and costly testing process would be required before they could be approved for sale. But in December, a federal district court ruled against the FDA, finding that the agency has the authority to regulate e-cigs as a “tobacco product,” and not under the more stringent terms of the Federal Food, Drug and Cosmetic Act. That means that the agency can regulate the dosages of nicotine in e-cigs and take measures to keep them out of the hands of minors, but can't effectively ban them from the marketplace.

That's where things stand, but the fight is not over. "We're gravely concerned about the implications of today's ruling," American Heart Association chief executive Nancy Brown told Dow Jones Newswire after the court's decision. "The appeals court has cleared the way for the industry to peddle these products to consumers without any scrutiny as to their safety or efficacy."

FDA spokesman Jeffrey Ventura added: "We are studying the opinion and considering next steps." But with the court having weighed in on the agency's ability to regulate e-cigs at the national level, expect the battle to get states to ban them to increase in intensity, as the anti-smoking groups and corporate lobbyists come together to protect Big Tobacco's right to kill you.