Nicotine is the major cause of drug addiction worldwide. Chronic nicotine exposure is responsible for numerous deleterious biophysiological effects and its withdrawal similarly results in negative sequelae.
Smoking has been identified as the leading cause of preventable death in the United States.1 Nearly one-third (28.6%) of all deaths or nearly half a million (480,000) Americans die from cigarette smoking.2, 3 Of particular note is nicotine’s prominent association with 12 malignancies, namely oral cavity and pharynx, larynx, trachea, lung and bronchus, esophagus, stomach, colorectal, liver, pancreas, renal, cervical, bladder, and acute myelogenous leukemia.2 This association can be traced to evidence of 70 carcinogens identified within tobacco smoke and 28 found in smokeless tobacco.2
Ten years ago, electronic cigarettes (i.e., e-cigarettes) entered the American and European markets with claims that they were a healthier alternative to smoking, they would manage nicotine cravings, and they could help smokers quit.4 Despite a lack of evidence of such, there is also additional troubling data that e-cigarettes serve as a conduit for future smoking and nicotine addiction.5, 6 Due to the unregulated paradigm in which e-cigarettes exist, little is known about their safety and efficacy. Of particular concern is their chemical content.
Propylene glycol and glycerol are nicotine solvents that create the vapor in e-cigarettes when heated. These products are used in brake and hydraulic fluids, antifreezes, and theatrical smoke. The vaporizing process emits formaldehyde which is categorized as a Group 1 carcinogen by the International Agency for Research On Cancer.7 Formaldehyde in high-voltage vapor is greater than that emitted from cigarettes which results in a user’s lifetime risk of cancer being 15 times greater than that of prolonged smokers.8 It has been linked to hematopoietic and lymphatic malignancies as well as a host of pulmonary and cardiac abnormalities (i.e., asthma, dyspnea, pulmonary edema, arrhythmia, tachycardia). Tobacco-specific nitrosamines are carcinogens formed during tobacco processing and are present in e-cigarettes’ vapor as are benzene and its derivatives identified as volatile organic compounds which are commonly used in paint thinners, varnishes, and cleaning products.9, 10
Historically, nearly 5 decades of anti-tobacco public health and legislative lobbying, policy, research, and education have transpired to reduce smoking behaviors, Yet unlike traditional smoking, e-cigarette use is currently allowed in most public places despite its potential deleterious effects such as passive exposure.11 There is also worrisome evidence that some at-risk populations may be targeted by media to use tobacco products.
In 2014, e-cigarette advertising reached 70% of all middle and high school students nationally.12 This has been associated with 13% of all high school and 4% of middle school students using e-cigarettes. Additionally, other at-risk cohorts may not be aware of or comprehend the hazards of continued smoking practices. Case in point is data demonstrating that two-thirds of cancer survivors continue to smoke following their cancer diagnosis.13
To me, this all sounds like history repeating itself. Yet we don’t need to relive the past torturous decades fighting to counter this public health hazard. We need to act on lessons learned starting with the 1970 precedent banning radio and television advertising of tobacco products. Intensive education targeted to the young, applying warning labels (i.e., as of 2016, the US Food and Drug Administration’s (FDA) authority has been extended to tobacco products which now requires warning verbiage be applied on all packaging and advertising materials about nicotine’s addictive properties), regulation, taxation, prohibiting sales to minors, and use in public places and vending machines, represent a multifaceted approach to stem the tide of this newest health threat.14
Oncology nurses need to be aware of evolving information about e-cigarettes as we are often asked about their use. I’ve been thinking about another historical note. Just as we were encouraged to “Just Say No” to drugs, perhaps we need to rally the warning, “Want to shorten your life? Just use tobacco.”
Centers for Disease Control and Prevention. Electronic Cigarette Use Among Adults: United States, 2014. 2015 Oct.
Henley SJ, Thomas CC, Sharapova SR, et al. Vital Signs: Disparities in Tobacco-Related Cancer Incidence and Mortality—United States, 2004–2013. Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report. 2016 Nov;65(44): 1212-1218.
Lortet-Tieulent J, Goding Sauer A, Siegel RL, et al. State-Level Cancer Mortality Attributable to Cigarette Smoking in the United States. JAMA Intern Med. 2016 Dec 1;176(12):1792-1798.
National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. 2014.
Zborovskaya Y. E-Cigarettes and Smoking Cessation: A Primer for Oncology Clinicians. Clin J Oncol Nurs. 2017 Feb 1;21(1):54-63.
Dutra L, Glantz SA. Electronic cigarettes and conventional cigarette use among U.S. adolescents: A cross-sectional study. JAMA Pediatr. 2014 Jul;168(7):610-7.
Merrill JK, Alberg AJ, Goffin JR, et al. American Society of Clinical Oncology Policy Brief: FDA's Regulation of Electronic Nicotine Delivery Systems and Tobacco Products. J Oncol Pract. 2017 Jan;13(1):58-60.
Jensen RP, Luo W, Pankow JF, et al. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med. 2015 Jan 22;372(4):392-4.
Cheng T. Chemical evaluation of electronic cigarettes. Tob Control. 2014 May; 23(Suppl 2): ii11–ii17.
Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014 Mar;23(2):133-9.
Schraufnagel DE, Blasi F, Drummond MB, et al. Electronic cigarettes: A position statement of the forum of international respiratory societies. Am J Respir Crit Care Med. 2014 Sep 15;190(6):611-8.
Centers for Disease Control and Prevention. E-cigarette ads reach nearly 7 in 10 middle and high-school students. Press release. 2016 Jan 5.
Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013 Jan 24;368(4):341-50.
US Food and Drug Administration. FDA’s New Regulations for E-Cigarettes, Cigars, and All Other Tobacco Products. 2016 Dec 30.
FDA Approves Onivyde for Advanced Pancreatic Cancer Marijke Vroomen Durning, RN, 10/27/2015 3 On October 22, 2015, the US Food and Drug Administration (FDA) approved Onivyde (irinotecan liposome injection, Merrimack Pharmaceuticals, Inc.), in combination with fluorouracil ...