At first, electronic cigarettes were a novelty — something a braggart in a bar might puff to challenge the established no-smoking policy, marveling bystanders with the fact that the smoke released from the device was merely harmless vapor.
Now, e-cigarettes are poised to be a billion-dollar industry, claimed as the solution to bring in smokers from out of the cold, both figuratively and literally, as e-cigarettes promise to lift the stigma of smoking and are increasingly permitted at indoor facilities where smoking is banned.
So, are e-cigarettes safe? Well, they're not great for you, doctors say. What's being debated is the degree to which they are less dangerous than traditional cigarettes.
E-cigarettes are battery-powered devices, often shaped like traditional cigarettes, with a heating element that vaporizes a liquid nicotine solution, which must be replaced every few hundred puffs. Nicotine is inhaled into the lungs, and a largely odorless water vapor comes out of the device. Puffing an e-cigarette is called vaping. [Vaping: How E-cigs Work (Infographic)]
Yet the industry's duplicity is clear to medical experts: E-cigarettes are marketed to smokers as a means to wean them off of tobacco (although studies show they don't help much); yet the same devices, some with fruity flavors, are marketed to young people who don't smoke, which could get them hooked.
Hooked? Yes, e-cigarettes are a nicotine-delivery system, highly addictive and ultimately harmful because of their nicotine.
Cancer and respiratory experts see the same ploy being played out today with e-cigarettes as was done in the 1940s with cigarettes, when America started smoking en masse. They often are distributed for free and pitched by celebrities and even doctors as cool, liberating and safe.
In an ad for a product called blu eCigs, celebrity Jenny McCarthy, infamous for encouraging parents not to vaccinate their children, encourages young adults to vape, enlisting words such as "freedom" and the promise of sex. In another ad, for V2 Cigs, a medical doctor named Matthew Huebner — who is presented without affiliation but is associated with a Cleveland Clinic facility in Weston, Fla. — implies that vaping is as harmless as boiling water.
As for the notion of e-cigs as liberating, the cost of a year's worth of e-cigarette nicotine cartridges is about $600, compared with $1,000 yearly for a half-pack a day of regular cigarettes.
As for whether they're safe, it's a matter of comparing the advantages of one addiction over another.
E-cigarettes not a patch
One would think that vaping has to be safer than smoking real cigarettes. Experts say they are probably safer, but safer doesn't mean safe.
"Cigarettes have their risk profile," said Dr. Frank Leone, a pulmonary expert at the University of Pennsylvania Medical Center in Philadelphia. And just about everyone who breathes understands the risks: circulatory disease and myriad cancers, for starters. "E-cigarettes might be better off compared to that profile. But that doesn't mean they don't have their own risk profile."
A top concern is the nicotine delivery rate, Leone said. With nicotine patches and gum, the nicotine delivery is regulated, with small amounts of nicotine released slowly into the bloodstream. But with traditional cigarettes and now e-cigarettes, heat creates a freebase form of nicotine that is more addictive — or what smokers would call more satisfying. The nicotine goes right into the lungs, where it is quickly channeled into the heart and then pumped into the brain.
Once addicted, the body will crave nicotine. And although nicotine isn't the most dangerous toxin in tobacco's arsenal, this chemical nevertheless is a cancer-promoting agent, and is associated with birth defects and developmental disorders.
A study published in 2006 in the journal Obstetrics and Gynecology, for example, found that women who chewed nicotine gum during pregnancy had a higher risk of birth defects compared to other nonsmokers.
This great unknown of possible negative health effects, along with the lack of regulation of e-cigarettes, scares experts like Leone. The products come bereft of health warnings. How many pregnant women will vape following McCarthy's promotion?
As for their merits in smoking cessation, e-cigarettes don't appear very helpful. A study published last month in the journal Addictive Behaviors found that most smokers who used them while they tried to quit either became hooked on vaping, or reverted back to smoking cigarettes. A study published Nov. 16 in the journal The Lancet found no statistically significant difference in the merits of the e-cigarette over the nicotine patch in terms of helping people quit.
Leone said that e-cigarettes might not help people quit smoking because the device keeps addicts in a state of ambivalence — the illusion of doing something positive to mitigate the guilt that comes from smoking, but all the while maintaining the ritual of smoking.
The Jenny McCarthy blu eCigs ad hints at this notion, with such phrases as "smarter alternative to cigarettes," "without the guilt" and "now that I switched…I feel better about myself."
Editors of The Lancet called promotion of e-cigarettes "a moral quandary" because of this potential to replace harmful cigarettes with something slightly less harmful yet just as addictive. Other researchers agree that e-cigarettes might help some people quit, but at a population level, converting millions of smokers into vapers still addicted to nicotine might not lead to the cleaner, greener, healthier world implied by e-cigarette manufacturers.
And then there's the issue of not knowing what's in the e-cigarette nicotine cartridge.
"It's an amazing thing to watch a new product like that just kind of appear; there's no quality control," said Dr. Richard Hurt, director of the Mayo Clinic's Nicotine Dependence Center in Rochester, Minn. "Many of them are manufactured in China under no control conditions, so the story is yet to be completely told."
The authors of The Lancet study, all based in New Zealand, called for countries to regulate the manufacturing and sale of e-cigarettes. The U.S. Food and Drug Administration, which does not approve any e-cigarettes for therapeutic purpose, said it plans to propose a regulation to extend the definition of "tobacco product" under the Tobacco Control Act to gain more authority to regulate products such as e-cigarettes.
Follow Christopher Wanjek @wanjekfor daily tweets on health and science with a humorous edge. Wanjek is the author of "Food at Work" and "Bad Medicine." His column, Bad Medicine, appears regularly on LiveScience.