Have e-cigarettes risen from the ashes?

June Wilson, PhD, RN
June.wilson@dominican.edu

Electronic nicotine delivery systems (ENDS), or electric cigarettes (e-cigarettes) are ubiquitous. Over 250 different types of e-cigarettes are in the United States alone, and according to Bonnie Herzog, Wells Fargo Bank tobacco analyst, sales of e-cigarettes will outstrip regular cigarettes within a decade.

E-cigarettes are battery-powered devices that provide nicotine to the user via aerosol.  When activated, an electronic heating element vaporizes the nicotine, various chemicals, and flavors, which are then carried to the individual’s lungs and bloodstream (McBride, 2013).  A factor attributed to their success is they provide the user nicotine without the tar or carbon monoxide byproducts found in tobacco cigarettes.

E-cigarettes are particularly appealing to young adults although some marketers deny they specifically target young adults. The liquid nicotine comes in a variety of flavors, including bubblegum, banana bread, and chocolate, which in themselves may appeal to youth.  Accessibility to e-cigarettes is unregulated in many states. They may be handed out at concerts, sold in mall kiosks, where youth frequent, and are readily available from many Internet sites.

The National Youth Tobacco Survey (2013) reported that electronic cigarette use more than doubled nationwide among U.S. middle and high school students between 2011-2012, with more than 1.78 million students trying e-cigarettes. These numbers may be higher, as some youth don’t associate other forms of nicotine delivery systems, such as vape pipes, hookah pens, or e-hookahs as e-cigarette use, although they can all deliver nicotine.  The number of youth using electronic nicotine replacement devices may be higher than reported because of the various nomenclatures used (Richtel, 2013).

Advertising

The sharp rise in e-cigarettes may be due in part to aggressive marketing campaigns that include celebrity endorsements (McBride, 2014; Walker, 2013) and high profile commercials, including one viewed by 100 million viewers during Super Bowl 2013 for the company NJOY—it explicitly stated: “friends don’t let friends smoke…. cigarettes you’ve met your match.”  E-cigarette ads are reminiscent of the 1950s cigarette ads—they are “sexy,” “harmless,” “youthful,” and “rebellious” (Walker, 2013).  These marketing techniques threaten to derail the success of decades-old marketing techniques that have de-normalized smoking.  An e-cigarette company’s marketing director explicitly referred to the “renormalization” of smoking through the use of “vaping,” a popular word for e-cigarettes, particularly among youth  (Fairchild, Bayer & Colgrove, 2014).

Celebrities such as Julie Louis Dreyfus and Leonardo DiCaprio used and thereby glamorized e-cigarettes during the Golden Globe awards.  Actress Katherine Heigl smoked her e-cigarette while on David Letterman, and actress and The View co-host Jenny McCarthy stated “smelling like an ashtray is not the ideal aphrodisiac” in her endorsement of Blu e-cigs.  Celebrity endorsement, sensationalism, and the portrayal of e-cigarettes in entertainment media are disconcerting because social factors influence teens to smoke.  Exposure to role models, including celebrities who smoke, is associated with increased susceptibility to smoking (Sargent, 2005).  In addition, viewing movies where people smoke tobacco is associated with higher receptivity to emulate that behavior (Sargent et al., 2002).  Thus, the celebrity who uses the e-cigarettes may have the same effect on the viewer as one who uses tobacco cigarettes.

Advertising for tobacco products has been banned from television since 1971 (Hodge, Collmer, Orenstein, Millea, & Van Buren, 2013); however, since the e-cigarette is not a tobacco product, this ban does not apply. Some are pushing the envelope; for example, in the United Kingdom an ad for e-cigarettes caused outrage among parental viewers after a sexually explicit commercial was aired during a show popular with the younger generation “I’m a celebrity.”  The e-cigarette was likened to a sexual object; the implication of oral sex was evident.

Advertising companies remind us that these devices are not regulated.  The actor Stephen Dorff in promoting the Blu e-cigarette implies that public health messages about smoking are paternalistic (Fairchild et al., 2014).  He explicitly states we have “freedom”; “you can smoke at a basketball game if you want to.”  He reminds us we are all adults who can decide for ourselves. We will “rise from the ashes.”  This is a strong message, especially for those who are questioning authority, as some teens do.

Efficacy of the e-cigarette

The data on the effectiveness of e-cigarettes as a tool to quit smoking are mixed.  In many studies, data suggesting the positive effects of e-cigarettes are collected from online e-cigarette forums where users tend to report favorable views of the products, thus biasing the data (Beard, Brose, Brown, West, & McEwen, 2013).

E-cigarettes provide an alternative to smoking and may help smokers avoid relapse (Etter & Bullen, 2014).  While they may help the older and well established smokers quit smoking (Polosa, Rodu, Caponnetto, Maglia, & Raciti, 2013), young adults do not use e-cigarettes to quit smoking; rather they tend to use them as a novelty (Sutfin, McCoy, Morrell, Hoeppner, & Wolfson, 2013).  There is likely a place for e-cigarettes within tobacco dependence treatment, yet oversight from the FDA and longitudinal research are needed to understand their long-term health implications.

Future of e-cigarettes and the media

Multi-media advertising is targeted towards the young adult.  Smart-phones apps keep consumers aware of the product and alert them to the nearest store to replenish liquid nicotine.  Studies are needed to examine the effects these apps have on e-cigarette purchasing behavior.

Little research exists on the number of young adults who use e-cigarettes as a gateway to traditional cigarettes.  However, even if young adults do not progress to tobacco, the skyrocketing use of e-cigarettes by youth (CDC, 2013) is of concern because of the still unknown health, environmental and societal impacts. For this reason, the effects of e-cigarette apps, aggressive multi-media marketing campaigns, and the bombardment of celebrity endorsements need to be further researched and understood.

References

Beard, E., Brose, L. S., Brown, J., West, R. & McEwen, A. (2013).  How the English stop smoking services responding to growth in use of electronic cigarettes?  Patient Education and Counseling, 94, 276-281.

Center for disease control (2013). E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012. Retrieved April 2, 2014 from http://www.cdc.gov/media/releases/2014/p0403-e-cigarette-poison.html

DeAngelis, T. (2014).  Are e-cigarettes a game changer? Retrieved April 1 from http://www.apa.org/monitor/2014/03/e-cigarettes.aspx

Etter, J. F. & Bullen, C. (2014).   A longitudinal study of electronic cigarette users. Addictive Behaviors, 39, 491-494.

Fairchild, A., Bayer, R. & Colgrove, J. (2014).  The Renormalization of Smoking? E-Cigarettes and the Tobacco “Endgame.” The New England Journal of Medicine, 370 (4), 293-295.

Hodge, J. G., Collmer, V., Orenstein, D. G., Millea, C. & Van Buren, L. (2013).Reconsidering the legality of cigarette smoking advertisements on television public health and the law. Journal of Law and Medical Ethics, 41(1), 369-373.

McBride, D. L. (2014).  E-cigarette use by children increasing.  Journal of Pediatric Nursing, 29, 92-93.

Polosa, R., Rodu, B., Caponnetto, P., Maglia, M., & Raciti, C. (2013).  A fresh look at tobacco harm reduction:  The case for electronic cigarette.  Harm Reduction Journal, 10 (1),  10-19. Sargent, J. (2005).  Smoking in movies:  Impact of adolescent smoking.  Adolescent Medicine, 16, 345-370.

Sargent, J., Dalton, M. A., Beach, M. L., Mott, L. A., Tickle, J. J., Ahrens, M. B. & Heatherton, F. (2002).  Viewing tobacco use in movies:  Does it shape attitudes that mediate adolescent smoking.  American Journal of Preventative Medicine, 22(3), 137-145.

Suftin, E. L., McCoy, T. P., Morrell, H. E., Hoeppner, B. B. & Wolfson, M. (2013). Electronic cigarette use by college students. Drug and Alcohol Dependence, 131, 214-221.

Walker, L. (2013).  Could e-cigarettes perpetuate addiction?  Kai Tiaki Nursing New Zealand, 19(9), 32-33.