FRONTLINE CANCER: The medical truth about e-cigs and hookahs

The number of Americans who puff cigarettes is steadily shrinking, from a high of 45 percent in the mid-1950s to just 18 percent of adults in 2012. It’s a big reason why the overall cancer mortality rate is also in decline. That’s the good news. The bad news is the rising popularity of two alternatives — electronic cigarettes and hookahs — both of which may be just as bad for users’ health, and ultimately lead to smoking tobacco cigarettes.

— Scott M. Lippman, MD, is director of UC San Diego Moores Cancer Center. You can reach him at

E-cigarettes are battery-powered devices that spritz nicotine-infused vapor into the mouth. Because they don’t produce a toxic cloud of secondhand tobacco smoke, promoters claim they’re safe, but the assertion is simply not true. Though not as polluting as conventional cigarettes, e-cigarette users, known colloquially as “vapers,” exhale a mixture of volatile organic compounds, heavy metals, ultrafine particles and aerosolized nicotine. Research has shown that people sharing the same air space with vapers have measurable levels of nicotine in their bodies.

Hookahs pull burning tobacco smoke through a basin of water, often infusing it with seemingly benign flavors like strawberries, chocolate mint and Pina Colada. But even after it has passed through water, the smoke from a hookah contains high levels of carbon monoxide, metals and carcinogenic chemicals.

Hookahs deliver the same addictive nicotine dose as cigarettes — as well as the same carcinogenic toxicants from burning tobacco and other additives.

Thus they can also be expected to increase the risk for the same diseases that afflict traditional smokers: cancer of the lungs, mouth, stomach and esophagus, reduced lung function and decreased fertility. Indeed, hookah smokers might be at greater risk. A typical one-hour hookah smoking session, which often occurs in a social setting, involves 200 puffs while the average cigarette lasts only 20 puffs. The volume of hookah smoke inhaled can be 180 times greater.

The marketing of e-cigarettes and hookahs is massive and alarming. E-cigarette sales in 2013 surpassed $1 billion. Advertising techniques used by the tobacco industry in the 1960s and ‘70s (before significant regulation) are being employed again, primarily targeting younger users.

Data from the 2012 National Youth Tobacco Survey shows e-cigarette use has risen among middle school students from 0.6 percent in 2011 to 1.1 percent last year. That might not seem like a particularly troublesome number, but these are kids between the ages of 10 and 14. Among high school students, e-cigarette consumption almost doubled, from 1.5 percent in 2011 to 2.8 percent in 2012.

Hookah use has risen from 4.1 percent to 5.4 percent over the same time period.

All of this is in addition to the thousands of children who try regular tobacco. According to the American Lung Association, almost 3,900 children under the age of 18 experiment each day with their first cigarette. More than 950 will become daily smokers. Half will ultimately die from their habit.

Though public indoor cigarette smoking is banned throughout California, hookah use is permitted in designated lounges, which Wael Al-Delaimy, MD, PhD, professor and chief of the Division of Global Health in the UC San Diego Department of Family and Preventive Medicine, says likely furthers the false impression that hookah is a safer alternative to cigarettes.

The marketing machine is even bigger for e-cigarettes, according to John P. Pierce, PhD, professor in Department of Family and Preventive Medicine and director for population sciences at UC San Diego Moores Cancer Center.

“There is a huge push from the industry to have e-cigarettes exempted from the clean indoor air rules so that people can smoke them inside, including in schools,” says Pierce.

Both Al-Delaimy and Pierce say that would be a mistake. “The argument is that e-cigarettes do not contain combusted tobacco product, which has hundreds of known carcinogens, but analyses of e-cigarettes show they do contain carcinogens, albeit less than cigarettes,” Pierce said. “There is no known safe level of these carcinogens.”

Rather than ease or erase constraints upon the public use of hookahs and e-cigarettes, many researchers and public health officials have urged the opposite.

Al-Delaimy, who has extensively studied rising hookah use among California youth, thinks policymakers should consider banning hookah lounges, “thus eliminating the implication that hookah smoking is safer and more socially acceptable than cigarette smoking.”

Pierce argues that e-cigarettes should be regulated.

“Without clear evidence that those exposed to the exhalation from these products do not have an increased cancer risk and that young people exposed do not become more likely to become cigarette smokers, e-cigarettes should not be exempted from the clean indoor air rules.”

In a letter to the U.S. Food and Drug Administration late last year, 40 Attorneys General urged the agency to issue proposed regulations addressing advertising, ingredients and sales of e-cigarettes to minors, something the FDA has long promised to do.

So far, that hasn’t happened. In the meantime, cities like Carlsbad and Vista have approved their own bans of e-cigarettes to minors and others like the San Diego Board of Supervisors are considering similar actions.

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  3. FRONTLINE CANCER: The courage to ask questions
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Posted by Staff on Jan 22, 2014. Filed under Health & Science, News. You can follow any responses to this entry through the RSS 2.0. You can skip to the end and leave a response. Pinging is currently not allowed.

10 Comments for “FRONTLINE CANCER: The medical truth about e-cigs and hookahs”

  1. MarkW

    So this article says that electronic cigarettes are just as deadly as regular combustion cigarettes? And that smoking electronic cigarettes is a gateway TOWARDS regular combustion cigarettes? From what studies can this information be drawn?

    “Research has shown that people sharing the same air space with vapers have measurable levels of nicotine in their bodies.” Citation, please!!

    I note that you cite the NYTS showing e-cig consumption has doubled, but where is the counterpoint that shows that teen usage of combustion cigarettes has dropped?

    Mr. Pierce alleges that the e-cig industry has pushed to allow smoking in schools. Is he daft? NO ONE has “pushed” this ludicrous idea, as NO ONE has pushed allowing minors to purchase or posess electronic cigarettes. In fact, nearly EVERY vendor of electronic cigarettes has voluntarily enacted policies that only allow 18-and-up, even in states with no law currently in place (there are some exceptions in regards to convenience stores, where some unethical clerks have sold various products to minors, but this is not an indication of fault within the e-cig industry).

    “There is no known safe level of these carcinogens.” Those same levels of carcinogens (known as Tobacco Specific Nitrosamines) are present in products such as nicotine gum and patches. Are those products unsafe, as well?

    Caution and a healthy level of skepticism is absolutely in order regarding electronic cigarettes and their effect on public health. Outright lies and scare-mongering is unprofessional and unethical. Many thousands of adult smokers world-wide have broken decades-long struggles with traditional combustion cigarettes, most after multiple failed attempts using “approved” methods.

  2. Electronic cigarettes are a gateway out of SMOKING TOBACCO CIGARETTES, as your study as shown, you have in one sentence managed to tell us that there is rapid decline in smoking and an uptake of electronic cigarette use, then tell us that there are downfalls to using e-cigs!!! The two messages don’t go hand in hand, try talking to VAPERS and stop number crunching your statistics, we vapers love vaping, we are healthier, wealthier and will be far happier when you get off this subject and onto the one that is dealing with the real killer that is the tobacco cigarette!!!

  3. Louise

    Sorry but your fear mongering article is not going to convince me that ecigs are cancerous. Also metal was tested in one companies ejuice only. My health is at its best since quitting smoking. My cholesterol levels have lowered . I can breathe much better. I have yet to hear about any proof that ecigs cause cancer. Many have been on this journey with me and none have got cancer. They all did get better health though!

  4. This article isn’t anything new, the same material has been recycled on a weekly basis for the last several months. In fact, just like its predecessors, this article is complete biased for banning e-cig. The arguments are structured to extend tobacco’s reputation onto e-cigarettes, and fails to mention any of its positives. Furthermore, the evidence is very vague and leaves our crucial information that would allow the reader to make an informed decision.

  5. It is sooooo obvious that e cigs are much safer and saving lives fricken daily. Yet these idiots have a hidden agenda, and the gov needs tobacco taxes so they aren’t in a hurry to save lives, they just want the moola. sick, sick, sick. Can’t wait for common sense to kick in, and ecigs is too far into the system and has too many advocates, and REAL LIFE true stories of people kicking the habit. Can you Imagine how much this would affect our health care policy and cost of health care, if the no. 1 killer, cigarettes is taken over by e-cigs? GET the facts for goodness sake.

  6. ChrisB

    What a piece of —- article.

  7. Randall

    This article is so slanted and biased id expect its author aspires to be a political commontator for fox news.

    1)electronic cigarettes are a less harmfull alternative to smoking convetional cigarettes. The american lung association will tell you the only safe thing to inhale is air and even thats getting kind of dicey these days.

    2) As pointed out in another comment this article lacks any kind of citation. Simply saying ‘research shows’ means nothing. I can say reserch show this article was autored by a twit and it means nothing. If you need specific studies drop me a line.
    I can show you a study that shows of all participants only ONE nonsmoker went on to use conventional cigarettes after initiating with electronics.
    I can show you studies that show secondhand(passive) vaopr is a non issue and of no danger.
    I can show you studies from the onasis center in greece showing ecigarettes have no effect on cardiac cells.
    I can show you studies from drexel school of public health, boston university, the london royal college of surgeons…
    There is a study to back up the articles claim of heavy metal and nano particulates from 2009. Too bad that study was later discredited for having specificly useing lowgrade products. Contemporary products has so vastly surpassed counterparts of 2009 that study is no longer relevent.

  8. Mike Hand

    Wow..this has to be one of the most missleading articles ever put out there concerning personal vaporizers (ecigs)
    lumping it in with Hookahs just to combine falsehoods about PVs as generalities is shameful journalism to say the least..
    PVs use flavoring, PG VG & Nicotine (nic at about 1/10 of tobacco proven in blood plasma testing)..there are NO known carcinogenics in ecigs PERIOD
    I took up ecigs over 3 years ago to break the pack a day habit..the health benefits have been significant to say the least..
    no more bronchitis was the most significant during this time period..
    cant you fanatics come up with some new material that even remotley reflects some of the actual science included in the existing 88 SCIENTIFIC studies already refuting virtually everything stated above about e-cigs…

  9. SlimJimJohn

    Obviously, you are in the same camp as those who say, “I see smoke, so it’s smoke”. A lot of us who use e cigs actually did some research into them; it appears as though you did too, but left out the details. One of these details being the amount of nicotine emiitted into a 4 cubic meter room is less than 1/10 that of someone exposed to cigarette smoke. You inhale more particulates walking down a city street than you would sitting in a car with someone vaping.

    If you want to publish information about something, use FACTS and not conjecture and omission. As far as e cigs being a “gateway to tobacco”, that seems to be the talking point, isn’t it? It’s quite the opposite, if you would take the time to find out.

    I’m really glad to see there are people here calling your bluff on this. It was a noble effort on your part.

  10. It’s all about the money! Cigarettes are known to cause cancer, they cause thousands of people to die every year, this is a fact! It is also a fact that the sale of cigarettes generates billions of $s every year. A lot of very powerful people would like e-cigarettes to go away.

    Almost every article written mentions e-cigarettes are known to be less harmful than smoking real cigarettes. If they are so worried about peoples health surely they should ban cigarettes and promote e-cigarettes as the alternative. This will never happen as like I said at the start, it’s all about the money!

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