Ban on electronic cigarettes to be voted on in 6 months

Although the Health Ministry s bill to bar tobacco advertising in the print media failed to pass in the Knesset a few months ago due to vigorous lobbying by cigarette companies, public health head Prof. Itamar Grotto hopes its initiative to prevent the sales of electronic cigarettes does not share the same fate.

After four months preparation of a draft to prohibit the sale of both e cigarettes and the chemicals that fill them, the document has been issued for the perusal of the public.

Grotto hopes the document will reach the Knesset and be passed in another half year, he said on Monday.

But as e cigs are a growing business here, legislation to protect public health could easily have trouble overcoming the vested interests.

Most but not all e cigs contain concentrated nicotine, an addictive drug and «medical poison,» according to the document. This quickly causes smokers to become dependent on tobacco and goes straight from the lungs into the bloodstream and the brain.

As increasingly stringent legislation has limited smoking in public places in Israel and abroad, causing tobacco companies to be worried about their income and addicted users to worry about when and where they can get their «fix,» companies have increasingly developed and put on the market electronic cigarettes that give users the feeling of smoking without polluting their environment.

These, said the ministry, can be «even more dangerous» than smoking nicotine.

Consisting of a battery, a device that heats the chemical and a container to store it, an electronic cigarette vaporizes the powder or liquid into synthetic smoke.

Although Israeli law bars smoking in public places, it has not yet set down any rules regarding the use of e cigs in public places or their advertisement and marketing.

A bill to include e cigs in existing prohibitions has been tabled in the Knesset.

The ministry stated that e cigs and related products «pose a severe health danger to the public.»

When the chemical is nicotine, it is a psychoactive stimulant, a poison and addictive, and it releases adrenaline and dopamine. It is also used as an agricultural insecticide. As the nicotine in e cigs is much more concentrated 24 mgs. during seven minutes of «smoking» compared to 1 mg. in tobacco it is more poisonous, the ministry document stated.

Smoking e cig chemicals also lasts longer than smoking a cigarette.

These chemicals and others in e cigs are not uniform or standardized among products.

Leaks from cartridges have also been reported, posing a «serious toxic risk» from exposure in the air and by being swallowed, including by children, the ministry continued. In 2012, a baby died after swallowing the content of an e cig cartridge.

Propylene glycol contained in cartridges can result in poisoning, the draft document said, and can cause respiratory problems through inflammation of the vocal cords.

Inhaling another chemical, diethylene glycol, can cause damage to the kidneys and nervous system and has reportedly killed over 600 people in various countries. It can also cause harm when swallowed.

Tobacco specific nitrosamines are carcinogenic.

As a result of e cig dangers, the US Food and Drug Administration has barred the sale of e cigs, while the World Health Organization has advised countries to warn its residents of exposure to e cigs, whose claims of reducing tobacco smoking «have not been proven.»

Thus the ministry document calls for the prohibition of the manufacture, storage or marketing of e cigs and their products.

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Are e-cigarettes a ‘gateway to nicotine addiction’? — health news — nhs choices

On average tobacco smokers die significantly younger and spend more of their shorter lives ill. Because e cigarettes can be marketed to young people, there is a worry that if they did lead to more conventional smoking, they could have a potentially disastrous impact on public health.

This current study does suggest that e cigarettes may not be the harmless alternative some believe, and may be acting as a «gateway drug» to conventional smoking.

However, it does not prove that is the case. It is quite plausible that existing teenage smokers are also trying e cigarettes for a variety of reasons.

The debate about the safety and regulation of e cigarettes is likely to continue until more robust long term evidence emerges.

Where did the story come from?

The study was carried out by researchers from the Center for Tobacco Research and Education at the University of California, San Francisco, and was funded by the US National Cancer Institute.

It was published in the peer reviewed medical journal, JAMA Pediatrics.

The Mail Online coverage was balanced and discussed the pros and cons of e cigarettes. It also usefully brought in some wider research from 75,000 Korean adolescents «which also found that adolescents who used e cigarettes were less likely to have stopped smoking conventional cigarettes».

What kind of research was this?

This was a cross sectional study looking at whether e cigarette use was linked to conventional cigarette smoking behaviour among US adolescents.

E cigarettes are devices that deliver a heated aerosol of nicotine in a way that mimics conventional cigarettes while delivering lower levels of toxins, such as tar, than a conventional combusted cigarette. They are often marketed as a safer alternative to regular smoking, or as a way of helping people quit traditional smoking.

The devices are not currently regulated in the US or the UK, meaning there are limited or vague rules concerning appropriate advertising. The researchers say e cigarettes are being aggressively marketed using the same messages and media channels that cigarette companies used to market conventional cigarettes in the 1950s and 1960s. These include targeting young people to get a new generation of smokers hooked on nicotine for life.

The researchers outline how studies have demonstrated that youth exposure to cigarette advertising causes youth smoking. Meanwhile, electronic cigarettes can be sold in flavours such as strawberry, liquorice or chocolate, which are banned in cigarettes in the US because they appeal to youths.

Given the potential for a new generation to be hooked on nicotine and then tobacco smoking in this unregulated environment, the researchers wanted to investigate whether e cigarettes were associated with regular smoking behaviour in adolescents.

What did the research involve?

The researchers used existing smoking data collected from US middle and high school students in 2011 (17,353 students) and 2012 (22,529) during the large US National Youth Tobacco Survey. They analysed whether use of e cigarettes was linked with conventional tobacco smoking and smoking abstinence behaviour.

The National Youth Tobacco Survey was described as an anonymous, self administered, 81 item, pencil and paper questionnaire that included

  • indicators of tobacco use (cigarettes, cigars, smokeless tobacco, kreteks southeast Asian clove cigarettes , pipes, and «emerging» tobacco products)
  • tobacco related beliefs
  • attitudes about tobacco products
  • smoking cessation
  • exposure to secondhand smoke
  • ability to purchase tobacco products
  • exposure to pro tobacco and anti tobacco influences

Smoking behaviour was categorised as

  • conventional cigarette experimenters adolescents who responded «yes» to the question «Have you ever tried cigarette smoking, even one or two puffs?»
  • ever smokers of conventional cigarettes those who replied «100 or more cigarettes (five or more packs)» to the question «About how many cigarettes have you smoked in your entire life?»
  • current smokers of conventional cigarettes those who had smoked at least 100 cigarettes and smoked in the past 30 days
  • ever e cigarette users adolescents who responded «electronic cigarettes or e cigarettes, such as Ruyan or NJOY» to the question «Which of the following tobacco products have you ever tried, even just one time?»
  • current e cigarette users those who responded «e cigarettes» to the question «During the past 30 days, which of the following tobacco products did you use on at least one day?»

Data on intention to quit smoking in the next year, previous quit attempts and abstinence from conventional cigarettes was also collected. The analysis was adjusted for potential confounding factors such as race, gender and age.

What were the basic results?

The main analysis included 92.0% of respondents (17,353 of 18,866) in 2011 and 91.4% of respondents (22,529 of 24,658) in 2012 who had complete data on conventional cigarette use, e cigarette use, race, gender and age. The mean age was 14.7, and 5.6% of respondents reported ever or current conventional cigarette smoking (of these, 5% currently smoked).

In 2011, 3.1% of the study sample had tried e cigarettes (1.7% dual ever use, 1.5% only e cigarettes) and 1.1% were current e cigarette users (0.5% dual use, 0.6% only e cigarettes).

In 2012, the 6.5% of the sample had tried e cigarettes (2.6% dual use, 4.1% only e cigarettes) and 2.0% were current e cigarette users (1.0% dual use, 1.1% only e cigarettes).

Ever e cigarette users were significantly more likely to be male, white and older. The rates of ever tried e cigarettes and current e cigarette smoking approximately doubled between 2011 and 2012.

The main analysis found use of e cigarettes was significantly associated with

  • higher odds of ever or current cigarette smoking
  • higher odds of established smoking
  • higher odds of planning to quit smoking among current smokers
  • among e cigarette experimenters, lower odds of abstinence from conventional cigarettes

How did the researchers interpret the results?

The researchers’ interpretation was clear «Use of e cigarettes does not discourage, and may encourage, conventional cigarette use among US adolescents.»

They added that, «In combination with the observations that e cigarette users are heavier smokers and less likely to have stopped smoking cigarettes, these results suggest that e cigarette use is aggravating rather than ameliorating the tobacco epidemic among youths. These results call into question claims that e cigarettes are effective as smoking cessation aids.»


This study found US adolescents who use e cigarettes are more likely to smoke conventional cigarettes. They also have lower odds of abstaining from conventional cigarettes than those who don’t try e cigarettes. On the flip side, e cigarette users were more likely to report planning to quit conventional smoking.

The research sample was large, so is likely to provide a relatively accurate picture of the smoking behaviour of US adolescents.

These results suggest that e cigarettes may not discourage conventional cigarette smoking in US adolescents, and may encourage it. However, because of the cross sectional nature of the information, it cannot prove that trying e cigarettes causes adolescents to take up conventional smoking. There may be other factors at play.

And indeed, smoking tobacco cigarettes may cause teenagers to take up e cigarettes. For example, the type of person who may want to try smoking in the past could only try conventional smoking. Nowadays, they have e cigarettes as an option too.

Retrospectively trying to work out if they would have taken up conventional smoking had they not tried e cigarettes first is not possible. This question would require a cohort
study that tracks behaviour over time. You would then be able to see which smoking method they took up first and if one led to the other. This was not possible using the data the researchers had to hand in the current study.

Conventional smoking has been a public health priority for many decades because, on average, smokers die significantly younger (more than a decade in some groups) and they spend more of their shorter lives ill. Consequently, any product that may increase the rates of conventional smoking among the young such as e cigarettes has serious and widespread health consequences.

Currently, regulation around e cigarettes is minimal, but there are plans to introduce stricter rules in the UK. In the meantime, this study provides some evidence that e cigarettes may not be the harmless, safe alternative some believe, and may be acting as a gateway drug to conventional smoking.

The research stops short of proving this, so the debate on whether e cigarettes should be treated similarly to conventional cigarettes, through advertising and sales restrictions, is likely to continue.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.