Lippman: Medical truths concerning e-cigarettes and hookahs

By Scott Lippman, M.D.

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.

Dr. Scott Lippman

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.

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 piña 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 1970s (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, M.D., Ph.D., 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, Ph.D., 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 County Board of Supervisors are considering similar actions.

It took decades of hard science to convince policymakers that tobacco consumption posed a real and deadly threat to human health, including that of non-smokers. All evidence points to a similar menace with e-cigarettes and hookahs. Their increasing use threatens to undermine years of progressive thinking and improved public health.

Scott M. Lippman, M.D., is director of UC San Diego Moores Cancer Center. His column on medical advances from the front lines of cancer research and care appears monthly. You can reach Dr. Lippman at

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Posted by Staff on Jan 31 2014. Filed under Columnists. 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.

6 Comments for “Lippman: Medical truths concerning e-cigarettes and hookahs”

  1. Frank

    Aside from the smoke vs vapor contest – nobody disputes the fact that nicotine is one of the most addicting substances a human can ingest. As with all other addictions, it is an addiction created by the user that he/she didn't otherwise have. Thus, like all addicts, a nicotine user puts himself / herself in bondage and becomes a slave to a substance. That substance rules their lives. It takes their money and their health, limits freedom and self control, and occupy's their time. I can't recall ever encountering a nicotine user, when asked if they really would rather not have that as part of their lives, say "no". The nicotine 'delivery system' industry is an enemy to society. Don't aid them by even trying to excuse one nicotine delivery system over another. There is no such thing as a substance addiction that isn't pathetically harmful on several levels.

    • Say-what?

      Sorry Frank, but your generalization is not based on facts. Nicotine is no more addictive than caffeine. It is a dependency, not an addiction. Real cigarettes, on the other hand, can indeed be quite addicting, due to the cocktail of ingredients which combine into an addictive substance. It is the combo of ingredients in a real cig that are addicting, not the nicotine. Vapers, on the other hand, once detoxed from the real cig, happily and contentedly proceed to dilute their nicotine levels to reach their goal. Some want to be nicotine free, others prefer the benefits that nicotine provides. Nicotine is actually beneficial in restoring cognitive skills, calming the nerves, healing neurological ailments, and helps many to focus. Nicotine is useful in defending against Alzheimer's, Parkinson's, Coilitis cancer, and more. It is not evil. In fact, if you research, you'll discover that it grows in vegetables as well as in other plants. Our bodies are geared for it, complete with receptors.
      For a more thorough look at nicotine, Google pfizers nicotrol Inhalator, the FDA's approval, and neurological studies. Dr. Farsalinos has proven that nicotine in eCigs does not stiffen the arteries, does not kill cells, and in fact, actually multilevel the good cells that smoking killed.

      • Frank

        Outside of Peter Killeen, emeritus professor of psychology at ASU, who's 'hypothesis' ventured in 2009 you have presented as fact and who you deftly failed to note as the source of your assertion, I cannot find., from scanning hundreds of top web results for the query: 'nicotine is not addictive', any other person or study or even theory on earth that even begins to posit or support such a notion.

        Ah yes, the venerable FDA – the folks that approved Thalidomide, Vioxx, Bextra, and dozens of other wonder drugs that turned out, in practice, not so 'approvable'
        As we all know, government is a world beater when it comes to what's good for us – especially in the healthcare and drug arena! So take all the nicotine you want people. You can easily quit whenever you want. The FDA approves it!

  2. Roger

    Hundreds of thousands if not millions of Americans have either comletely quite smoking tobacco or dramatically reduced their intake of cigarettes, as a result of "e-cigarettes" (which vaporize instead of burning tobacco). No one denies that this is an improvement. Calls to ban or dramatically restrict the sales of vaporizing devices to adults ought to be viewed in the same light as a demand to remove filters from tobacco cigarettes, or an insistance that only high-proof alcoholic spirits should be sold instead of beer and wine. After 50 years, the reduction in American smoking rates has slowed dramatically … until e-cigarettes. And we want to stop or slow down this trend? That makes no sense for society, and it makes no sense for tobacco smokers. That's why the American Society of Public Health Physicians and the National Drug Policy Alliance have both endorsed e-cigarettes as a less harmful strategy for smokers who can't otherwise quit.

    • Frank

      Not only "Hundreds of thousands, if not millions…" have benefited from "e-cigarettes", but it's likely billions have benefited since you wrote your comment 2 days ago! By next month it should be trillions!

      The American Society of Darwin Awards and the National Twit Association have endorsed automobiles as a less harmful strategy than motorcycles for drunk drivers who just can't seem to quit driving drunk.

  3. rothenbj

    "nobody disputes the fact that nicotine is one of the most addicting substances a human can ingest." That's hogwash sent to you by the zealots that have created the anti-tobacco movement and is used to keep extracting taxes from a minority of the population. If the statement were true, why would the FDA approve long term use of NRT products as safe for long term use?

    There's no question that nicotine is addictive to some extent, but once you break the habit/ritual of smoking. the nicotine becomes far less important. It took me 6 months to break a 43 year 2-3 PAD habit using e cigs and in those six months I was never without my vapor device. Eventually the hand to mouth habit broke down and now I use it occasionally.

    If you're going to talk addiction and being a slave to a substance, there are a lot of them in society- caffeine, sugar, carbohydrates, alcohol and salt as examples. Most people have some form of addiction. Nobody questions that smoking is bad for you but they're not going to ban it. Smokeless tobacco and e cigs are 95-9x% safer than smoking and should be encouraged rather than demonized. The sale of Big Pharma snake oil has proven to be very ineffective in getting people to stay quit from smoking, it's time to promote tobacco products that will.

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