Where There’s Smoke… As E-cigarette Sales Escalate, So Too Does the Controversy

From 1954 to 1999, his masculine image became perhaps the most influential branding vehicle of the century. The campaign’s creator, Leo Burnett Worldwide (the creative firm that also gave the world the Jolly Green Giant and Tony the Tiger), won numerous accolades for imagery credited with popularizing filtered cigarettes, turning Marlboro into the largest-selling brand of cigarettes in the world, and Philip Morris USA into the largest tobacco company in the world.

But later, those same images became tinged with irony — and tragedy — as the health concerns related to smoking began to multiply a half-century ago. In 1957, then-Surgeon General Leroy Burney declared the official position of the U.S. Public Health Service to be against cigarettes, based on evidence of a causal relationship between smoking and lung cancer. This was followed by the 1964 “Report on Smoking and Health,” which spelled out, in great detail, the connections between smoking and many serious health problems.

As the smoke began to clear — and three of the actors who had appeared in Marlboro-related advertisements died of lung cancer — Marlboro cigarettes, specifically Marlboro Reds, earned the nickname ‘Cowboy killers.’

Decades later, the number of smokers in the U.S. is falling, but many continue to struggle with an addiction to nicotine. Numerous websites offer a road to recovery with options ranging from quitting cold turkey to hypnosis; from nicotine patches to gum. The latest product — and controversy —in this realm is the e-cigarette, or e-cig.

Dr. Gary Hochheiser, a thoracic surgeon and chief of the Thoracic Surgery Division at Baystate Health, who has performed thousands of surgeries on those with lung cancer, emphysema, and other benign and malignant esophageal diseases, describes an e-cig as a “nicotine delivery device,” one that heats liquid nicotine and turns it into a vapor for inhaling. The ‘e’ part of the name refers to the electronic heating element in the device.

“It’s not like burning tobacco and all the chemicals that are in cigarettes that we think are responsible for people getting lung cancer; we don’t think that nicotine is the major source for all that,” he told HCN. “Theoretically, it should be better for you than a real cigarette. If we could take 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the cigarette smokers and make them e-cig users, that could be a huge national health benefit.”

But others in the healthcare industry remain skeptical about this product, and they center on words like ‘theoretically’ and ‘should’ that are used by Hochheiser and many others. That’s because little is about the e-cig, now being sold and promoted by the major cigarette makers, and how its use can impact consumers who buy into the considerable hype concerning them.

“We really don’t know what’s in them,” said Lynn Ostrowski, director of Brand & Corporate Relations for the Springfield-based insurance company Health New England, adding that traditional cigarettes already have their own health-risk profile, which links smoking to various cancers and lung-compromised conditions.

However, no such dossier exists on e-cigs, she went on, adding that they are currently both unregulated and heavily promoted, and already account for almost $500 million in annual sales in the U.S.

Erika Sward, assistant vice president for the American Lung Assoc. in Washington, D.C., agreed, and said the U.S. Food and Drug Administration (FDA) has officially failed to find e-cigarettes safe and effective in helping smokers quit.

“The American Lung Assoc. is concerned about e-cigarettes because we don’t know what’s in them or the health consequences of what their use might be,” said Sward. “It’s important for people to know that e-cigarettes are a tobacco product and will be regulated by the federal government as a tobacco product, but as of today, they are not regulated at all.”

The obvious targeting of teens with fruity flavors, and marketing the inhalation of e-cig vapor as ‘vaping,’ not smoking, is concerning to many in the healthcare field, who see similarities between the marketing tactics of 50 years ago, including the Marlboro Man, and current efforts to promote e-cigs.

As the controversy heats up, HCN takes an in-depth look at this new product and the growing concerns surrounding it.

While it may seem that Hochheiser is promoting a questionable product, he explained to HCN that his reasoning is due to the ongoing, desperate need for some effective alternative to smoking tobacco.

Hochheiser said that 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the surgery he performs is for lung cancer, the number-one cancer killer among Americans. The bulk of his lung-cancer patients are in their 60s and 70s — those, he said, who have been smoking since they were teens, many of them because they simply haven’t been able to quit.

“If it turns out to be safe and it is a way to transition people off cigarettes, then I tell my patients that it’s a good use temporarily,” said Hochheiser.  “I don’t condone using it long-term, but as a short-term device to try to get off cigarettes, I think the benefits probably outweigh the risks.”

But it is the use of words like ‘temporarily’ and ‘probably’ that concern people like Sward and Ostrowski, who contend that there is still far too much mystery concerning this product for it to be promoted by anyone, and that e-cig makers are blending unsubstantiated claims with time-tested methods for hooking young people on their products to create what could be a dangerous situation.

Sward compares the e-cig marketing explosion to the Wild West, where curious elixirs were hyped as cure-alls. Those making e-cigarettes are claiming that the vapor tubes can help smokers quit and that they are a healthier alternative for smokers and non-smokers alike, but there is no validation of these claims from the FDA or any other agency.

“The American Lung Assoc. has gone a few rounds with the tobacco industry, and we know not to trust it at its word,” she told HCN. “We’re also troubled because we see this new product, but the same tobacco companies behind them using the same old marketing tactics; they’ve spent millions of dollars on their advertising already.”

Even though the federal government will eventually regulate e-cigs in a tobacco-product category, Sward continued, Lorillard, the world’s third-largest cigarette maker, which acquired Blu eCigs in 2012, has been pushing bills in state legislatures not to be regulated as a tobacco product, but in a new category called ‘vaping products.’ “They don’t want to be included in smoke-free laws, and they don’t want to be subjected to tobacco taxes.”

However, legislators in New York and Arizona have already introduced measures that would ban the sale of e-cigs to minors. In Alabama, Kentucky, Mississippi, and Utah, bills would extend smoking bans in public areas to include e-cigarettes. According to Casey Harvell, director of Public Policy for the Massachusetts chapter of the American Lung Assoc., the state Legislature currently has a bill to ban the sale of e-cigs to minors and to ban vaping in enclosed public places.

But the true contents of e-cigs and federal regulation of these products is what Sward and Ostrowski want to see, with both pointing to recent studies that show various metals, in addition to formaldehyde, benzene, and nicotine, found in tested e-cigs.

“It’s an industry that’s come under attack for the past 30 years, ever since the Surgeon General announced that the single most important thing you could do for your health was to quit smoking,” said Ostrowski.  “The tobacco companies are just figuring out how to reinvent themselves.”

Sward agreed and said the switch is identical to what the tobacco companies did when the public became concerned about full-flavored cigarettes, and created ‘light’ and ‘low-tar’ cigarettes, making claims that those versions were better for people to use.

“I think the whole ‘light’ campaign they had was a farce because they knew there was no difference with the risks,” added Hochheiser. “However, I think this is a totally different product, but one of the problems is we don’t know what the full risk is, and it’s totally unregulated.”

But as he mentioned, it does hold potential — and possibly vast amounts of it — for helping to wean people off cigarettes, an already-proven killer.

Hochheiser points to the patch and nicotine gum as products that have proven help smokers quit, but he added that the ‘psychosocial’ act of smoking, holding a cigarette (or e-cig in this case), and bringing it to the lips to inhale is part of the hardcore smoker’s mental addiction.

Hochheiser said that once a patient learns they have lung cancer, the regret of a lifetime of smoking is typically 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}. But only 40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of those patients actually stop for good, which is a glaring example of how addictive cigarette smoking is, he said.

“You’ll notice that the targeting of cigarettes is toward younger people because people don’t start smoking cigarettes in their 30s or 40s,” he said. “We know they get people to start smoking in their teens and 20s. That way, they hook them for life.”

And this track record for success, if it can be called that, raises more concerns about e-cigs and the ongoing, and blatant, attempts to target young audiences.

“They’ve even come out with new flavors,” said Hochheiser, who, with a sarcastic laugh, added rhetorically, “now, who’s that for?”

The use of celebrities to push e-cigs, such as actress Jenny McCarthy for Blu, is also disconcerting for Ostrowski, Sward, and global medical entities.

Blu’s advertising shows McCarthy saying that vaping e-cigs offers “freedom to have a cigarette without the guilt.” The guilt she refers to is two-fold: guilt about smoking in public, and guilt about health concerns.

“When you get these celebrities behind things, all of a sudden it lends credibility to something,” but it’s a false credibility, Ostrowski added. “They boost those sales, and that is really troublesome because they don’t even know what they are backing.”

And the marketing strategies seem to be working. A September 2012 study by the Centers for Disease Control and Prevention showed smoking rates among teens are flat; however, in one year, e-cig use among middle- and high-school students doubled.

The Lancet, the world’s foremost medical journal, is officially concerned about the use of celebrity endorsements for e-cigarettes, which hype smoking independence, glamour, and the alleged safety of vaping.

The explosion of candy and fruit flavors, like cotton candy, atomic fireball, and Cap’n Crunch, is what Sward equates to “the crown jewel” of big tobacco companies’ playbook to addict kids.

“So they’re actually creating this new generation of people who are going for the flavor and are going to be hooked on these e-cigs,” added Ostrowski.

Hochheiser sees the tobacco companies trying to capitalize on something new.

“They probably don’t even know what they’ve got — they just saw these e-cigarette companies as competition,” he said.

Meanwhile, consumers buying these products don’t really know what they have, either, said Sward and Ostrowski, adding that there is no evidence to back up the marketing claims — and no itemized list of ingredients, either.

So for most of the parties involved, e-cigs are an unknown quantity, and as long as they remain as such, the controversy about their use — and the parallel efforts to promote them — will continue.