The month of March was a busy one for legislators concerned about the proliferation of e-cigarette use among the country’s youth, the lack of regulation for sales of e-cigarettes to minors at state and federal levels, and advertising directed at young people that glamorizes “vaping” in much the same way that conventional cigarettes were once marketed.

On March 12, Governor Dannel P. Malloy introduced legislation to ban the sale of electronic cigarettes, electronic delivery systems, and other vapor products to those under the age of 18. Electronic cigarettes, also known as e-cigarettes or vape pens, are currently not regulated in the state.

The new law would have Connecticut joining 27 states that already prohibit the sale of e-cigarettes and other related devices to minors.

In a press release issued that day, Gov Malloy said, “More than 75 percent of young people who have tried e-cigarettes also report smoking conventional cigarettes. This legislation will strengthen our prevention efforts and help reduce tobacco use among young people.”

E-cigarettes are battery-operated devices that contain doses of nicotine or non-nicotine vaporized solutions, often flavored. Many have refillable cartridges. Other e-cigarette devices are disposable.

Fashioned to look like conventional cigarettes, cigars or pipes, the solution is nicotine dissolved in propylene glycol, a product “Generally Recognized As Safe” by the Food and Drug Administration (FDA). Vape pens are nicotine-dispensing devices that look more like pens than cigarettes, an attraction for users who do not want to be associated with smoking cigarettes.

It is not known if e-cigarettes may lead young people to try conventional cigarettes, which are known to cause disease and lead to an early death.

E-cigarette smokers slowly inhale the water-based vapor into the mouth, holding it there and then exhaling it through the nose or mouth, if desired. It is not intended to be inhaled quickly into the lungs. Nicotine is absorbed into the system through the vapor contact with mouth and nasal linings, instead. While giving the user the sensation of smoking regular cigarettes, e-cigarettes do not give off smoke.

It has been suggested by some e-cigarette manufactures that e-cigarettes are a safer alternative, useful in decreasing or preventing the use of conventional cigarettes, as they contain far fewer chemicals and carcinogens than conventional cigarettes.

Information at WebMD.com states that while e-cigarettes may be safer due to that fact that no burning smoke is inhaled, nicotine is still being delivered to the system. Nicotine is dangerous for those with heart problems and can be harmful to arteries when used over time. There is also evidence of nicotine use being linked to increased blood clotting, branchiospasm of the lungs, and gastrointestinal issues. While not a carcinogen, nicotine may stimulate tumor growth, and there is evidence of increased risk for birth defects when pregnant women use nicotine.

Because these products have not been submitted to the FDA for evaluation or approval, at this time the agency has no way of knowing, except for the limited testing it has performed, the levels of nicotine or the amounts or kinds of other chemicals that the various brands of these products deliver to the user. The FDA notes that e-cigarettes have not been studied to the extent that consumers can evaluate long-term harm potential, how much and what kinds of chemicals are inhaled, or how much nicotine a particular e-cigarette contains — as well as if there are actually any benefits to using e-cigarettes.

TobaccoHarmReduction.org asserts that the effects of nicotine itself are hardly more than those of caffeine, increasing blood pressure and heart rate temporarily.

Nicotine affects certain neurotransmitters in the brain that reenergize the body and enhance good feelings. It is both a stimulant and relaxant, and the rise in blood glucose levels reduces appetite. These are all reasons that users continue using nicotine products and crave the drug when it is discontinued.

The negative social stigma of smoking is mitigated with the use of smokeless tobacco or e-cigarettes, which do not produce secondhand smoke or leave a lingering scent. E-cigarettes, it could be argued according to tobaccoharmreduction.org, are a “reduced-harm” alternative for smokers.

Reduced Harm? No So Fast…

Marianne Mitchell, a pulmonary nurse practitioner with Western Connecticut Health Network (Danbury Hospital), does not believe that e-cigarettes are necessarily a reduced-harm alternative. The real problem, she said, is that there is no scientific proof of safety.

“We don’t even know what’s in them,” she said, and she is alarmed by recent findings that the biggest ingredient in e-cigarettes is the same chemical found in antifreeze. The popular hookah pipes are no better, said Ms Mitchell. “The water in a hookah doesn’t filter out the bad things,” she said, and the common practice of passing the hookah pipe around puts users at risk for infectious diseases.

Refilling the cartridges with illegal substances and smoking them is a problem, too, she said. As a pulmonary nurse practitioner, it is the act of smoking that worries her. Lighting something on fire or vaporizing it and inhaling it increases the chance of “screwing up your lungs,” she said.

Many of her patients have tried e-cigarettes in attempts to quit smoking regular cigarettes, but because they can never get the amount of nicotine from the lower nicotine e-cigarettes, they tend to suck very hard, inflaming the inside of the lungs.

“A heavy smoker will inhale,” she said. Nor, said Ms Mitchell, who has run the smoking cessation program “Quit Now” for 12 years, do e-cigarettes help smokers to stop.

In the course of her experience, she has seen an upswing in e-cigarette usage, and is not surprised.

“The top four tobacco companies have bought into e-cigarettes. The tobacco companies are making money off of our youth,” she said. What is new and exciting always has appeal to young people, Ms Mitchell pointed out.

“My philosophy,” Ms Mitchell said, “is that I don’t like to see anybody inhale anything.”

Donna Culbert, director of health for the Town of Newtown, and Judy Blanchard, district health coordinator for the Newtown School System, shared concerns about e-cigarettes.

“Part of our concern is the attitude, and it’s hard to get information about [e-cigarettes},” said Ms Blanchard. “The [e-cigarette] industry took us by surprise,” she said, “and I don’t think the medical community is convinced that e-cigarettes are safe.”

Because her job is predominantly working with youth, Ms Blanchard said it will be necessary to keep an eye on the message young people are getting about e-cigarettes.

“There is an appeal to young women, especially, [that nicotine] can be good for weight reduction; and that they can get a little buzz. The message they are getting is that they won’t get lung cancer, so they think [using e-cigarettes] is safe,” she said.

Nicotine is one of the most addictive drugs, though, she stressed, and while the immediate physical effects may not seem much more dangerous than caffeine, “you would not be drinking coffee every 20 minutes, which is about how long nicotine affects the body,” she said. For that matter, said Ms Blanchard, she does not think caffeine is a good option for young people, either.

Calls to poison control centers centered on nicotine exposure are on the increase, Ms Culbert said, and refillable cartridges present another potential issue. “Kids will put illegal chemicals into the cartridges,” she said.

Ms Culbert has additional questions about use of the product.

“What is the reason for using nicotine?” questioned Ms Culbert. If people are using nicotine for either its stimulating or sedating effects, “there are other ways to address [those issues],” she said.

Growing Concerns

As part of educating students about drug use, Ms Blanchard said, “We are trying not to label drugs. We are trying to say, you need a healthy body. You need plenty of rest, plenty of exercise, and a nutritious diet to be at your best. It’s a bigger picture of what is beneficial, especially to a developing body.”

What any drug — nicotine, alcohol, or caffeine — is doing to the growing body needs to be addressed. Why a young person feels the need to alter who they are and how they feel is a question that needs to be asked, said Ms Blanchard.

Whether conventional or e-cigarettes, “you are ingesting an addictive ingredient,” Ms Culbert said. “I don’t want to see it for adults, and I certainly don’t want to see it in our kids,” she said.

Recent research at the University of California at San Francisco (UCSF) disputes the wisdom of e-cigarette usage in youth, as well. It found that “adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking. The study of nearly 40,000 youth around the country also found that e-cigarette use among middle and high school students doubled between 2011 and 2012, from 3.1 percent to 6.5 percent.”

The Centers for Disease Prevention and Control (CDC) reported in the September 6, 2013, Mortality and Morbidity Report the increase in e-cigarette use among American youth in grades 6-12, from 2011 to 2012.

“E-cigarette experimentation and recent use doubled among US middle and high school students during 2011-2012, resulting in an estimated 1.78 million students having used e-cigarettes as of 2012,” the report said in part. “Moreover, in 2012, an estimated 160,000 students who reported e-cigarette use had never used conventional cigarettes. This is a serious concern because the overall impact of e-cigarette use on public health remains uncertain,” according to the report, with “potentially harmful constituents” being documented in some e-cigarette devices, “including irritants, genotoxins, and animal carcinogens.”

Nicotine Hazard

Additional concerns regarding the use of liquid nicotine to refill some e-cigarette products have arisen. Spilling liquid nicotine on the skin while refilling an e-cigarette cartridge can expose a person to a hazardous amount of nicotine; for adults, that is 40 to 60 mg of nicotine; for children, just 10 mg can be lethal. A lack of regulation means that the amount of nicotine in a product can vary, and flavorings added to the liquids are attractive to curious young children.

In the April 4, 2014, Morbidity and Mortality Report issued by the CDC, data shows that calls to poison centers in the United States for exposure to e-cigarettes increased from one in September 2010 to 215 in February 2104. Toxicity can occur with exposure to the nicotine liquid, usually contained in cartridges inserted into a nondisposable e-cigarette. E-cigarette exposure causing vomiting, nausea and eye irritation were mainly among small children.

The public “should be aware that e-cigarettes have the potential to cause acute adverse health effects and represent an emerging public health concern,” cautioned the CDC report.

Responding to a March 24 New York Times article on that subject, US Senator Richard Blumenthal issued a statement that said, in part, “Exploding use — misuse and abuse — of liquid nicotine makes federal regulation even more vital to stop poisoning and other public health hazards … E-liquids are the new snake oil of cigarette marketing, with purity and potency varying widely, and no safeguards…”

How It’s Sold Locally

At Newtown Convenience Store, 22 Church Hill Road, manager Niel Vyas said he does not carry any liquid nicotine or flavored liquids for e-cigarettes. The small display of Logic e-cigarettes buried behind other impulse items on the counter is mainly the disposable product and extra cartridges, and a few of the $20 rechargeable e-cigarette products.

The typical Newtown Convenience customer for the e-cigarette, which Mr Vyas said has been picking up in popularity, is a person trying to quit conventional cigarettes. Because the e-cigarette is more economical over the long run than tobacco products, some of the e-cigarette customers are people trying to cut costs.

Regardless of the law, “We do not sell [e-cigarette products] to minors,” Mr Vyas said, nor has he been approached by young people wishing to purchase them.

The Big Y on Queen Street has two typical buyers, said Clair D’Amour-Daley, vice president of corporate communications.

“First, are the twenty-somethings looking for the trendy thing to do,” she said. The other typical buyers of e-cigarettes are smokers trying to quit or cut back, she said. Like Newtown Convenience, the Big Y has the same restrictions and rules for e-cigarette purchases as applies to regular cigarettes, refusing sales to anyone under the age of 18.

E-cigarette usage does not seem to have reared its head at Newtown Middle School, said Principal Tom Einhorn, and the district Drug/Alcohol/Tobacco Policies are written to cover the use of e-cigarettes. Interim Principal Jeffrey Jaslow of Newtown High School said there is not much talk about e-cigarettes on the high school campus, with only three or four incidents of students using e-cigarettes on school property, earlier this year.

“Such behavior is treated as the equivalent of violation of tobacco use policy,” he said, with prohibitions applying to staff and students alike.

Still, alarmed at the seductive advertising directed at young people by e-cigarette makers, Congresswoman Elizabeth Esty, Connecticut’s Fifth District, announced on March 27 that she has introduced the “Protecting Children from Electronic Cigarette Advertising Act.” The bill would prohibit advertising, promoting, or marketing e-cigarettes in a manner that increases children’s use of e-cigarettes; allow for enforcement by state attorneys general and other officials; and provide a mechanism for states to work with the Federal Trade Commission.

Citing reports from the CDC, and offering links of side by side comparisons of cigarette ads before they were banned and current marketing by e-cigarette manufacturers, Ms Esty noted that research shows that nicotine is addictive and may impact brain development of children and adolescents, and called e-cigarette advertising “shameless efforts to addict our kids.”