Boom in e-cigarette sales divides smoking campaigners

In the window of a hairdresser’s in a west London side street, there is an array of brightly coloured little bottles, which the casual passer by who doesn’t look too closely might assume had something to do with hair conditioning. References to best «juice» don’t immediately give the game away. You probably need to have come across vaping already to realise that you are looking at the paraphernalia beloved by aficionados of e cigarettes.

Wetherspoons has banned them and Megabus routinely announces to passengers that they cannot use them on its coaches after a scare when police were called because somebody saw steam drifting out of a holdall. But a grassroots revolution is going on and e cigarettes are booming. More than 1.3 million people now use them in Britain.

The public health community is seriously divided about e cigarettes. Some believe they are a breakthrough and will save thousands of lives because it is the tar in tobacco that kills not the nicotine. But others say we should be trying to wean people off an addictive drug like nicotine they fear that e cigarettes are already being used as a stalking horse by the tobacco companies, who want to re normalise the pariah habit.

This month, British American Tobacco ran its first advert on television in years for a brand of e cigarette made by a subsidiary company. Philip Morris has also got in on the act. It is making e cigarettes that look and are marketed just like the tobacco products that were banned from our screens and magazines.

Steve, who runs the Vapeshack above the hairdresser’s in West Ealing, says it’s not cool young people who come through the doors in search of a healthier nicotine fix but older people who have tried and failed to kick the smoking habit. «It’s hardcore smokers who have tried everything. There was an Irish chap who use to smoke 70 a day. He bought a kit off me three months ago and he hasn’t had a cigarette since.

«He was in that theatre when the ceiling fell in at a performance of The Curious Incident of the Dog in the Night Time and he was just scrabbling on the floor looking for it his e cigarette .»

Steve himself had a 20 a day habit two years ago. «A friend of mine had a kit and I tried it and it was great. He got me one and that was it. I managed to well, you can’t call it quit because you still have the nicotine habit but I managed to change completely. I think it’s much more satisfying than patches and gum. It’s the action.»

He has never had a problem finding places to vape even on a flight to Spain with one of the bargain airlines. He surreptitiously blew vapour at the floor, only to realise that a couple of other passengers were vaping quite openly. He wouldn’t do it next to somebody who is eating though, he says. It has an odour a different one depending on what flavour you prefer.

The UK government wanted to clamp down on e cigarettes and have them all regulated as medical devices, which would require stringent testing. It has been wrong footed in Europe, where the European Parliament has decided they are consumer products unless the cartridges contain more than 20mg/ml of nicotine. Although the Department of Health said that it would ban them from sale to under 18s, it is still working out what else to do. «We have no further clarification on how the UK will regulate e cigarettes,» said a spokesman. «This issue is still being considered as part of the new European tobacco products directive that is in the final stages of negotiation. Once the directive is finalised, we will work through the best way of implementing it.» A request for an interview with the chief medical officer, Dame Sally Davies, who has voiced concerns about e cigarettes, was turned down.

A damning report commissioned by the World Health Organisation last December from three leading scientists Rachel Grana, Neal Benowitz and Stanton A Glantz of the Center for Tobacco Control Research and Education at the University of California said «Television and radio have been unavailable to the cigarette and other tobacco companies to market their products in the US (as well as much of the world) since the 1970s. E cigarette advertising on television and radio is mass marketing of an addictive nicotine product for use in a recreational manner to new generations who have never experienced such marketing. This pervasive marketing may have implications for existing smokers as well.»

Martin McKee, professor of European Public Health at the London School of Hygiene and Tropical Medicine, has spoken out more forcefully than most against e cigarettes and has been denounced in turn by the vaping community, many of whom are now evangelical about their new habit.

«My view at the moment is that these are things that have been around since the 1960s and people had not paid attention to them. Then suddenly the tobacco industry got interested,» he said. He is alarmed to see celebrities such as Lily Allen vaping and an advert for e cigarettes broadcast during Downton Abbey. More recently, the Netflix remake of House of Cards featured Kevin Spacey as US vice president Frank Underwood substituting an e cigarette for tobacco. «Addiction without the consequences,» remarks Underwood.

«The advertisements they are using are almost identical to the ones the tobacco industry used historically,» said McKee, who believes this is about the rehabilitation of cigarettes.

«The smoking ban in public places has been self enforcing,» he said. But steam rising from an e cigarette can look very like smoke rising from an old style fag. Other drinkers in pubs will be less and less likely to intervene once they’ve made that mistake a couple of times, he believes.

McKee acknowledges that a lot of people in public health say e cigarettes are much safer than tobacco. «Absolutely, but that is not the issue here,» he said. «They are missing the point.»

But while some suspect Big Tobacco’s involvement, the e cigarette lobby accuses Big Pharma of dirty tricks. Drug companies make the nicotine gum and pills that have been licensed for stopping smoking and are handed out by the NHS. The pro vaping lobby cites a letter sent to all MEPs from one of these companies, arguing that the permitted nicotine level in e cigarettes should be no higher than 12mg/ml and claiming that nicotine is as toxic as strychnine and arsenic.

Rubbish, say those who support e cigarettes, who liken the effect of nicotine to that of perfectly legal caffeine and alcohol. In fact, they say, it is a great deal safer than alcohol.

The leading voice in support of e cigarettes in Britain is Clive Bates, who a decade ago headed Ash Action on Smoking and Health which fought the tobacco companies full time. He has always been in favour of harm reduction, he says, a phrase in common parlance in drug addiction.

«Obviously the best thing is to quit nicotine completely, but we don’t consider stopping all alcohol or caffeine consumption as a public health goal,» he said. «There is no reason to think they are less harmful drugs than nicotine.

«There is a deep conflation in public health between the drug nicotine and the harm caused by smoking. If tobacco was not causing so much harm, we would not be so concerned,» he said. Before we understood the cancer and heart risks, smoking was considered a way to relax and alter mood, he said.

E cigarettes are a way to take the harm out of the drug use. As things stand, 1 billion people will die from smoking related diseases, the WHO says. » There are not really many other good ideas,» said Bates, who points to the use of snus in Sweden a derivative of snuff. Sweden has a smoking prevalence of 13%, compared with 27% in Britain and 28% across Europe, according to the Eurobarometer figures (the UK government’s figure is 20%). «They have dramatically lower levels of cancer and heart disease,» he says.

There are fears that young people who would not have smoked may take up e cigarettes, but Bates says there is little evidence of that as yet. Most people using the devices appear to have
been heavy smokers.

Bates is not the only anti smoking campaigner to support e cigarettes. Derek Yach, who led the successful tobacco control initiative of the WHO over a decade ago, agrees with him. «My view is that we failed to build a nicotine policy till now. E cigarettes and related non combustibles are growing super fast, and if they do displace tobacco, it could be the most positively disruptive technology ever, with the potential to bring down the death rate faster than the quit programmes we now have.»

But there is scant actual scientific evidence yet that e cigarettes help people quit smoking and some people do both. The official position of most public health bodies in the UK is that stopping the nicotine habit is the way to go.

Dr John Middleton, vice president for policy at the Faculty of Public Health, said his institution believes that «e cigarettes have some potential to help people to stop smoking and therefore reduce the harms that causes. This is particularly the case where people already smoke and have long term conditions.»

But the faculty is concerned about the e cigarette firms’ mass marketing. «We believe incitement to nicotine addiction of any kind should be discouraged. Mass marketing of e cigarettes is bringing the smoking habit to more young people, just at the time when young people are being discouraged from starting smoking tobacco.»

The faculty, like the British Medical Association, believes e cigarettes should be regulated as a medicine and it wants curbs on its advertising and promotion.

Around 1.3 million Britons now use e cigarettes Photograph Mike Segar/Reuters Getting up a head of steam

E cigarettes date back at least to 1963, when Herbert A Gilbert patented a non tobacco cigarette that heated a nicotine solution and produced steam, but it was never manufactured.

Many small companies have set up to manufacture a range of devices and nicotine liquids. But the big tobacco companies were late entrants to the field.

Flavours matter, say supporters. Nicotine has none. Many people progress from a tobacco flavour to fruits and mint but the companies deny these are designed to attract young people.

Look alike disposable e cigarettes, resembling the tobacco version, are also similar in cost, but many people graduate to other sorts of devices with a refillable tank and longer battery life, which are less expensive.

E cigarette supporters oppose the new EU rules enforcing medical regulation over 20mg/ml of nicotine, saying hardened smokers need more than that to switch. They also object to rules restricting the advertising of flavours.

Most people agree e cigarettes need some sort of regulation, at least to ensure standards, which are currently very variable. The WHO says while there are less toxins than cigarettes, there are some.

This article was amended on 24 February 2014 to correct the name of Wetherspoons, from Weatherspoons as the original said.

E-cigarettes: healthy tool or gateway device? —

The topic, though, remains as polarizing a health issue as sex education or diet sodas.

An e what?

The e cigarette was actually developed by a pharmacist in China.

The pharmacist, Hon Lik, was a three pack a day smoker. That was nothing unusual more than 300 million people in China are regular smokers. But when Lik’s father, who was also a heavy smoker, died of lung cancer, Lik decided he had to come up with an alternative that wouldn’t kill him.

Most scientists believe nicotine itself, while highly addictive, is not what causes cancer for smokers or for the people around them who breathe their second hand smoke. Instead, it’s the toxic chemicals that are created when tobacco and filler products burn that are dangerous.

If there was a way to get nicotine addicts their fix without the burn, you just might avoid the health problems. Nicotine then becomes as harmless as any other addictive substance, such as caffeine, some experts say.

So Lik developed an e cigarette a device that uses a small battery to atomize a pure liquid solution of nicotine. Nothing is burned. There is no ash. There is no smoke. There is nicotine, and then there is flavoring added for taste.

Essentially the person using these inhales a kind of vapor that looks like fog from a fog machine. A recent review of all the scientific research done on e cigarettes by Drexel University professor Igor Burstyn concludes «current data do not indicate that exposures to vapors from contaminants in electronic cigarettes warrant a concern.»

In plain language, Burstyn concludes «It’s about as harmless as you can get.»

«I wouldn’t worry at all if someone was smoking one of these by my kids,» Burstyn said. «From a pure health perspective, these are not as bad as a cigarette.»

E cigarettes came to the U.S. market around 2009. The CDC now estimates about one in five American smokers have tried an e cigarette that’s about 6% of all adults.

There are e cigarette stores, but now you can also buy them online or in convenience stores. Some look like regular cigarettes some look like pens or thumb drives.

First you buy a starter kit, which costs between $40 and $130. In the kit is the e cigarette, a charger and a few cartridges. The cartridges typically last as long as a 20 pack of cigarettes and sell for around $10. You can also buy a bottle of e liquid to refile the cartridge yourself.

The anti e cigarette camp

Critics point out e cigarettes come in kid friendly flavors such as gummy bear, atomic fireball candy and cookies and cream. It makes them worry that e cigarettes will become a gateway to encourage kids to develop a lifelong nicotine addiction or worse, try the real thing.

Only about 20 states specifically forbid the sale of e cigarettes to children.

Tobacco use has been on the decline with kids it’s about half what it was in the mid 1990s. But the latest CDC study shows a growing number of middle and high school students have tried e cigarettes.

One in 10 high school students surveyed said they had tried e cigarettes last year. That’s double the number from 2011. One high school in Connecticut banned them after the principal said administrators dealt with at least one incident involving e cigarettes every day.

CDC director Tom Frieden characterized this trend as «deeply troubling.»

But as far as risky behavior goes, it’s still a tiny fraction of students. The survey showed about 3% of these kids said they had used one in the last 30 days. By contrast, 39% of students said they drank some amount of alcohol in the past 30 days, 22% binge drank and 24% rode with a driver who had been drinking.

The real problem is that 88% of adult smokers who smoke daily said they started when they were kids, according to the CDC. Kids who start down the path to using e cigarettes may stick with them for life.

«So much is unknown about them and what the long term complications could be with their use,» said the American Lung Association’s Erika Sward. «Bottom line, we don’t know what the consequences of using them are, and we are very troubled that kids would find them attractive.»

E cigarettes are unregulated in the United States no laws make manufacturers tell you what you are actually inhaling. The unknown is one of the many qualities of e cigarettes that the American Lung Association doesn’t like.

It’s «a complete unregulated Wild West,» Sward said. She wants the FDA to move quickly with regulatory oversight, which she says would make manufacturers disclose what the actual ingredients are in each of the 250 or so brands available.

In 2009, a FDA test on a small number of e cigarette samples found «detectable levels of known carcinogens and toxic chemicals to which users could potentially be exposed.» They found diethylene glycol in one cartridge at a 1% level this is an ingredient used in antifreeze and can be toxic to humans in large quantities. Diethylene glycol is also found in some dental products and in some pharmaceuticals.

After that study, the FDA banned the sale of e cigarettes. They warned e cigarette smokers that they were inhaling «toxic» and «harmful» chemicals. However, in 2010, a court ruled that «the FDA had cited no evidence to show that electronic cigarettes harmed anyone,» and stores could go on selling them.

The early e adopters

On the other side of the debate are the passionate supporters of e cigarettes. Many who use them say it is the first thing that has helped them stop using cigarettes something more than 90% of smokers fail to do with any of the existing FDA approved methods. There are blogs and message boards dedicated to them. And there are countless impassioned testimonials from the people who use them.

Florida resident Craig Lashley says they’ve changed his life.

«I got tired of being like that little kid in ‘Peanuts’ who had the cloud of smoke following him all the time,» Lashley said. «I didn’t like the way I smelled when I smoked, and I didn’t like what smoking said about me, especially to kids.»

He discovered the e cigarette about a year ago and hasn’t smoked a regular cigarette since.

He says he smells better, feels better and spends a lot less about $10 a week on e cigarettes. He used to spend about $45 a week on regular cigarettes.

«I like the feel of blowing smoke,» Lashley said. «It seems to me like (e cigarettes are) a healthier alternative.»

A growing number of respected physicians and scientists agree, and they say these products could end a major health problem.

«Electronic cigarettes and other nicotine containing devices offer massive potential to improve public health, by providing smokers with a much safer alternative to tobacco,» the Royal College of Physicians says. «They need to be widely available and affordable to smokers.»

The latest study, published in the British journal the Lancet, examined whether people who used them as an alternative to smoking would abstain from using regular cigarettes.

The New Zealand authors studied the behavior of 657 people who were trying to quit. One group got nicotine patches, another got nicotine e cigarettes and others got placebo e cigarettes without the nicotine.

Over a period of six months, only a tiny fraction of the people in the study actually quit smoking.

People using the nicotine e cigarettes quit at a slightly better rate compared with those using the patch, though. Some 7.3% using the e cigarettes abstained from smoking traditional cigarettes compared with the 5.8% who stopped with the patch. About 4.1% stopped with just the placebo e cigarettes.

It was such a small number of people who quit that the authors concluded «more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels.»

Dr. Michael Siegel, a physician who has spent the past couple decades working on tobacco contro
l initiatives, has been surprised by the negative reaction to e cigarettes from so many people in the public health sector. Siegel says the studies he’s done have shown e cigarettes are a help.

«True we don’t know the long term health effect of e cigarettes, but there’s a very good likelihood that smokers are going to get lung cancer if they don’t quit smoking,» he said. «If they can switch to these and quit smoking traditional cigarettes, why condemn them?»

Siegel theorizes the e cigarettes might look too much like smoking.

«It’s ironic the very thing that makes them so effective … drives the anti smoking groups crazy. But what makes them so effective is it mimics the physical behaviors smokers have, which is something the patch can’t do.»

Siegel does believe there is an urgent need for more regulations.

Ray Story, founder of the Tobacco Vapor Electronic Cigarette Association, agrees. He says his association has also pushed for age verification legislation.

«When you have these companies trying to promote these as something they are not, and you have stores that sell them in the candy aisle, you are going to have a problem,» Story said. «If they are officially categorized as a tobacco product, you get an automatic age verification put in place.

«Nicotine is addictive, and we want the federal government to create guidelines and a structure that will confine these to being sold as adult products.»

Lashley says no matter what the debate, he will continue to spread the e cigarette gospel to his fellow adults.

So far, his co workers have been receptive to the idea. He used to be the only one with an e cigarette on smoke breaks. Now he says he’s got more than a dozen colleagues doing the same.

One colleague, though, complained about it.

«He said ‘I’m sick of all these people smoking electronic cigarettes,» Lashley said. «When I asked him why he said. ‘Simple, now I can’t bum any off of them.’ «