Exposure to secondhand smoke (SHS) remains a key threat to public health. Secondhand smoke contains more than 50 known chemicals, the majority of which are toxic, carcinogenic, and are potential irritants to the eyes and lungs. The health effects of SHS is far-reaching and is a major cause of morbidity and mortality in the country. The emergence of e-cigarettes has the potential to reduce SHS and tobacco particulate matter in the environment. The purpose of this paper was to evaluate existing evidence to determine whether e-cigarettes could address the issue of secondhand smoke.
A narrative review was conducted to evaluate the existing evidence. Findings from the review show that e-cigarette smoke is more than ten times safer than normal cigarette smoking. In addition, it emits less toxic substances. The only main emission is nicotine, which suggests that non-users may be inadvertently exposed to nicotine, especially in close areas. Despite the safety of e-cigarettes, there few ethical issues that arise from its marketing and promotion, including potential normalization of the use of tobacco and its potential role as a gateway to cigarette smoking.
This review concludes that e-cigarettes are only a short term solution to the SHS problem, and further research is required to determine the actual impact on health outcomes of users.
Secondhand smoke is a major and pervasive problem. It comprises of a mixture of thousands of compounds, including particulate matter emitted when tobacco products are combusted and exhaled by smokers. Sureda, Fernandex, Lopez, and Nebot (2013) report that secondhand smoke (SHS) comprises more than 50 known chemicals, the majority of which toxic, irritant and are often thought to be carcinogenic.
Martins-Green et al. (2014), in their animal model study, reported that SHS is more toxic than smoking. Chemicals released by SHS are often deposited on skin, liver and other surfaces, and become toxic over time. The potential threat posed by SHS to human and animal health cannot be overemphasized.
According to Martins-Green et al. (2014), SHS is also associated with third-hand smoke through the deposition of contaminants on surfaces. The effect of these toxins on human health is significant. Through multiple mechanisms, SHS affects the liver, lungs, and skin healing. It poses a significant health threat not only to those who smoke or inhale the SHS but also affects those who come into contact with contaminated surfaces. Some of the health consequences include inducing inflammation diseases such as Asthma and obstructive pulmonary diseases. Furthermore, it impedes the healing of wounded skin. Sureda et al., (2013) also note that there is scientific evidence that SHS is associated with adverse health outcomes, including lung cancer, and acute cardiovascular disorders in both children and adults. Recent evidence suggests that SHS is a respiratory and eye irritant for non-smokers. It is estimated that more than half a million death annually are the direct result of SHS (Oberg et al., 2011).
In response to the health effects of SHS, countries across the world have passed legislation to combat smoking and to promote smoke-free areas. Since 1964 after the U.S surgeon general declared smoking a threat to public health, state, federal and local governments have implemented policies to combat tobacco use through smoke-free legislation, public campaigns, and tax increases for tobacco products (Mello, Bigman, Sanders-Jackson, & Tan, 2016). Restriction of smoking has resulted in positive developments including prevention of initiation, reduced motivation to smoke, and reduction in exposure to SHS. However, the rise of electronic cigarettes or e-cigarettes poses a threat to public health and could potentially undo the progress that has been made over the years (Mello et al., 2016).
E-Cigarettes have become the replacement to the normal (standard) type of cigarettes which do not employ the use of an electronic nicotine delivery system (Callahan-Lyon, 2014). Applicable data show that there has been a notable increase in the use of electronic cigarettes. The quantity of users exposed to cigarette-associated aerosol and product constituents has rapidly risen over the last five years (Callahan-Lyon, 2014). E-cigarettes have been accessible for only a decade but have experienced strong popularity in the last few years. E-cigarettes are different from traditional cigarettes, which burn almost 600 additives, of which 69 are carcinogenic (Hua & Talbot, 2016). E-cigarettes burn a liquid solution known as e-liquid which contains a few flavors and nicotine. The purpose of this research is to assess the negative health effects of e-cigarettes and assess whether they can play a key role in reducing SHS exposure in the US population.
As a lifestyle, smoking is a dangerous choice that in many cases results in an increased risk of premature death or severe cause of death such as increased cancer risk and heart disease for the smoker and secondhand smokers. The habit also has adverse health risks for the unborn children of pregnant women who engage in the smoking lifestyle. The involuntary inhale of smoke from smoking people also has a serious health implication for non-engaging adults and children ( Bond, 2018). As a result, smoking cessation proves as a critical, effective, and efficient healthcare intervention that can be undertaken to help in mitigating these risks.
A former smoker’s chance of suffering from heart illness reduces to half within a year of quitting smoking as compared to a continuing smoker. Also, the probability of suffering from lung cancer reduces by half between the fifth and fifteenth year after quitting. Further, the risk of cancer-related death decreases and becomes similar to that of a nonsmoker. However, the addictive nature of smoking makes it hard to stop and hinders people from abandoning the behavior ( Bond, 2018). While there is a possibility of stopping through behavioral intervention, the introduction of a complementary treatment such as nicotine replacement therapy increases the rates of smoking cessation. These pharmacological treatments provide behavioral support and supplies therapies while reducing the effects of traditional smoking to the smokers and the nonsmokers.
Quitting is still a challenge to many smokers therefore, e-cigarettes are the best alternative approach. Electronic cigarettes are increasing in popularity around the world as a control measure to reduce smoking. E-cigarettes use does not involve the use of tobacco. It uses nicotine and other components before inhalation. The lack of tobacco combustion reduces toxicant exposure to the users and non-users as compared to traditional cigarettes. E-cigarettes create a vapor for its users instead of tobacco smoke, delivering less amount of nicotine than regular cigarettes. There are constant anti-tobacco efforts, and the introduction of electronic cigarettes has been marked as a less harmful mean to traditional cigarettes and a cessation aid. The use of E-cigarettes to people who smoke reduces cancer risk (Simon, 2018). It reduces the exposure to more than 70 known carcinogens, which are in the traditional cigarette smoke. Using electronic cigarettes reduces toxins exposure and cancer-causing components in tobacco. Though e-cigarettes are not without health risks, there are less harmful to smokers and passive smokers than conventional cigarettes. When e-cigarettes replace traditional cigarettes, there is a reduction of many toxicants and carcinogens, reduced risk of developing heart problems, as well reduction of adverse health outcomes.
There are multiple studies that have shown that e-cigarettes are safer than traditional cigarettes, yet could pose a threat to human health, although the evidence is not conclusive. A systematic review by Fernandez et al. (2015) of eight studies reported that e-cigarettes often emit particulate matter that could potentially be harmful to the health of non-users. They found that e-cigarettes contain specific toxic compounds, including volatile organic compounds, heavy metals, carbonyls, and nicotine. In one of the studies included in the review, the level of particulate matter in home environments that had not non-smokers was similar to home environments where members used e-cigarettes (Fernandez et al., 2015). However, the level of particulate matter and potentially toxic substances increased significantly during puffs. The findings of the research suggest that e-cigarette may release potentially toxic substances, although at a lower rate than traditional cigarette smoking.
Czogala et al. (2014) conducted two studies to evaluate SHS exposure from e-cigarette smoke. In the study, the scholars measured airborne markers of volatile organic compounds, carbon monoxide, particulate matter, and nicotine. They generated e-cigarette smoke from three brands. Findings from the study showed that the nicotine level produced by the e-cigarettes was ten times less than that produced from smoking tobacco cigarettes. However, the study also found that e-cigarettes do release nicotine into the air, which means that involuntary exposure to nicotine for non-users is possible especially in closed environments (Czogala et al., 2014). The advantage of e-cigarettes over traditional cigarette smoke is that it exposes non-users to nicotine only, and but does not expose them to many other toxic substances that are associated with tobacco smoking.
An experiment on components of SHS in e-cigarettes by Saffari et al., (2014) also show that e-cigarettes release less toxic chemicals as compared to normal cigarette smoke. In the experiment, the researchers evaluated e-cigarette from four popular European brands. They recorded a large reduction in emissions of particulate matter, toxic chemical specifies, and organic compounds by e-cigarettes as compared to cigarette smoke. Furthermore, they found that the emission of organic compounds was 100 times less, while emission of elements was ten times less in e-cigarettes when compared to normal cigarettes. However, they did find that e-cigarettes were associated with higher emissions of toxic metals in indoor environments (Saffri et al., 2014). Based on the findings, the researchers concluded that the use of e-cigarettes was an improvement from the perspective of public health as exposure to toxic elements in SHS was significantly lower as compared to normal cigarettes.
Nonetheless, the safety of e-cigarettes may be eroded if it acts as a gateway to other drugs. A cross-sectional study of Korean students based on 2011 data found evidence of higher use of cigarettes among youths who used e-cigarettes (Glantz & Bareham, 2018). One of the most important findings of the study was that e-cigarettes were used in addition to traditional smoking. Majority of e-cigarette users were students who had tried to quit smoking. Similar findings were reported by a US cross-sectional study. However, the US study also reported that e-cigarette use accelerated the progression from experimentation of cigarette smoking to actual smoking. Experimenters who had used e-cigarettes had higher odds of progressing to become an established cigarette smoker (Glantz & Bareham, 2018).
These findings cannot be used to make inferences between e-cigarettes and potential use as they are cross-sectional. Cross-sectional studies capture a phenomenon at a specific time and cannot reveal long term changes in the phenomenon of interest. Longitudinal studies are required to make such inferences (Glantz & Bareham, 2018). Nine longitudinal studies have, however, shown that e-cigarette smoking increases the odds of cigarette smoking (Glantz & Bareham, 2018). The studies show that the majority of users progressed from e-cigarette to cigarette smoking. Youths who had not used e-cigarettes were compared to those who had used e-cigarettes at baseline. When the scholars adjusted for behavioral, psychosocial, and demographic factors, they found that the risk of becoming established cigarette smokers quadrupled among the youth who used e-cigarettes (Glantz & Bareham, 2018).
Such findings may indicate that e-cigarette, despite its lower toxicity to non-users, may expand the tobacco epidemic by allowing youths who are at risk to experiment with tobacco products. The findings of a 2015 survey suggest that the process may be beginning (Glantz & Bareham, 2018). A small increase in high school users of tobacco products between 2014 and 2015 may signal an increase in tobacco use, which may further fuel the tobacco epidemic, given that those youths who use e-cigarettes will likely progress to cigarette smoking within a short period of time (Glantz & Bareham, 2018). Even with the advantages that e-cigarettes in relation to traditional smoking, a full-blown increase in e-cigarette use may be detrimental to public health efforts to reduce the use of tobacco products.
The use of tobacco is the main cause of illnesses that are preventable, disabilities, and high mortality in the US. Almost forty million people in the United States still smoke traditional cigarettes. Also, nearly 4.7 million school-going children in high school and middle school use at least one tobacco product, which include electronic cigarettes. In the United States, about 2000 youths less than the legal age smoke their first cigarette every day. Yearly the statistics show that nearly half a million people in America die an early death due to smoking or due to the exposure of secondhand smoke. In addition to this, another 16 million people live with a smoking-related illness in the US (CDC, 2018). Due to the high rate of smoking and lack of an alternative control measure, there is an expenditure of the almost $170 billion on health care to treat smoking-related illnesses in adults around the United States.
Secondhand smokes cause harm to children and adults. The only solution to protect nonsmokers is to try to eradicate smoke from smokers in all places. Most exposure to passive smoke occurs in workplaces and homes. This smoke exposes nonsmokers to toxins that cause life-threatening illnesses, such as lung cancer. According to the CDC, since 1964, an estimate of 2.5 million people who are nonsmokers have died from illnesses caused by exposure to secondhand smoke. Also, each year between 2005 and 2009, an estimated 34,000 deaths of nonsmokers were registered, as a result of heart diseases among adults in the US. Secondhand smoke exposure also contributed to more than 7300 deaths through lung cancer each year from 2005 to 2009 among nonsmoker adults in the US (CDC, 2018). As such, the use of E-cigarette guarantees less exposure to toxin harm to nonsmokers, which are contributed by tobacco smoke exposure.
A study of adult and children non-smokers who live in U.S public housing by Mason, Wheeler, and Brown (2015) illustrates the burden of SHS on non-smokers. The study quantified the economic burden using published estimates of mortality and morbidity. Mason, Wheeler, and Brown (2015) also relied on data from medical care costs, as well as lost productivity due to disease burden. According to the findings, 37,791 never smoking adults and children suffered from health issues related to exposure to SHS. The scholars further found that total direct and indirect medical costs for the population were $128 million and $176 million respectively. Majority of the costs arose from medical costs. From the findings, total societal costs were half of the costs that accrued from the costs that the individuals incurred to manage their health condition. Conclusively, the study established that exposure to SHS in public housing was associated with disease burden, and consequently societal costs. Reducing exposure to SHS could save non-smokers money that they use to manage the adverse medical conditions that may arise from exposure to SHS.
In another study, Yao et al., (2018) examined the healthcare costs associated with SHS among U.S. adults. The scholars examined data of 67,735 adult non-smokers for the years 2000, 2005, and 2010. Using data on emergency room visits, doctor visits, hospital stays, and homecare visits, the researchers sought to evaluate the impact of SHS exposure on healthcare costs. According to the scholars, exposure to SHS was positively associated with emergency room visits, and hospital stays, although the relationship between SHS exposure and doctor visit and homecare visits was not statistically significant. According to the findings, those who were exposed to SHS were 1.28 and 1.16 times more likely to spend time in hospital and visit emergency departments, respectively. Total annual attributable costs to SHS were $4.6 billion in 2000, $2.1 billion in 2005, and $1.9 billion in 2010. The fall in costs could be attributed to the fall in exposure, although the cost of exposure to SHS remains high. Further costs could be saved by reducing exposure to SHS.
E-cigarettes have changed dramatically over the past few years in their appearance and have enjoyed increased popularity as a result of increased marketing efforts. Policy and lawmakers and many public health organizations are concerned about the safe use and public health impact of these products as a result of the lack of disclosure of ingredients and lack of manufacturing standards. The US Food and drug administration began regulating E-cigarettes use in 2016 by classifying e-cigarettes as a tobacco product. This regulation leaves significant regulatory gaps while addressing key policy issues (FDA, 2019). Also, the regulation leaves out advertising restrictions of e-cigarettes. As such, it allowed e-cigarettes to continue to be widely promoted and marketed on the media.
Noticing the gaps left by the FDA’s regulatory authority, several states, and local governments have taken the initiative to regulate the sale, pricing and its usage to protect public health, reduce nicotine and tobacco usage in young people. These states have also worked to promote the implementation of tobacco-free laws, which also include e-cigarettes (Public Health Law Center, 2017). The use of these laws provides a framework and pointers for communities and policymakers to put into consideration when coming up of implementing laws that regulate e-cigarettes use. Without proper regulation, E-cigarettes use as a control measure of secondhand smoke, there is a high probability of abuse and exposure to passive smokers. Public health organizations regulate e-cigarettes by regulating its sales, its marketing, its price, its usage, its disposal, and its packaging. As such, there is minimal exposure to secondhand smokers with the use of electronic cigarettes.
In addition to regulatory consideration, there are several ethical issues that arise from the use of e-cigarettes. The first ethical problem that may arise is the increased use of e-cigarettes among non-smokers. A 2010-2013 data survey sampling U.S adults found that e-cigarette use was largely driven by smokers and those who quit smoking (Franck, Filion, Kimmelman, Grad, & Eisenberg, 2016). At present, it is unclear whether the proportion of users of e-cigarettes is driven by quitters or current smokers. However, concerns abound as to whether increased use of e-cigarettes would lead to an increase in the prevalence of nicotine use and consequently nicotine addiction. While there is limited evidence of the priming effect of nicotine, there are concerns that it could have a gateway effect on cigarette smoking. Principles of economic dictate that often when risk-minimizing strategies are available, more people are encouraged to engage in risky behavior (Franck et al., 2016). The same effect could be possible in the case of e-cigarettes.
The impact of replacing a high-risk activity with a low-risk activity can be explained through liberal and utilitarian perspectives. For instance, if e-cigarettes reduce risk of harmful health by 99%, for every smoker who switches to e-cigarettes, then 100 non-smokers would be needed to initiate use of e-cigarettes to erode the public health benefits (Franck et al., 2016). If e-cigarettes are 95% less harmful, then 20% of non-smokers would have to initiate use of e-cigarettes to offset the benefits associated with switching from cigarette smoking to e-cigarette (Franck et al., 2016). Thus, it is unlikely that switching to e-cigarettes would have a net adverse effect on public health. In practice, a sound public health policy that allows smokers to switch to e-cigarettes would not outweigh public health benefits that may emerge from lower emissions of SHS.
Another ethical problem is the potential normalization of smoking through advertisement and marketing of e-cigarettes. There is a probability that marketing and promotion of e-cigarettes could undo the progress that has been made in educating the public about the harms of smoking. Such a phenomenon could emerge if normalization of e-cigarette unintentionally encourages the public that smoking of tobacco is acceptable and normal (Franck et al., 2016). However, the probability of such an occurrence is difficult to study as it is based on the assumption that e-cigarettes can act as a gateway to cigarette smoking. However, there is the probability that the availability of e-cigarettes could potentially prevent smokers from quitting as they can sustain their addiction through e-cigarettes (Franck et al., 2016). The phenomenon should be studied as the prevalence of use of e-cigarettes increases, and the long term implications of use become clearer.
According to data from the CDC, reduction efforts to exposure of passive smoke among nonsmokers have delayed in the United States after nearly two years of progress. An estimate of 58 million Americans got exposed to passive smoke and other tobacco-related products during 2013-2014. This number included children of ages between 3 to 11 years (CDC, 2018). The disparities in exposure to secondhand smoke increased across demographic groups. The prevalence of exposure remained high in children, non-Hispanic Africa Americans, and individuals affected by poverty, especially those living in rental homes. These disparities in passive smoke exposure mostly increased among children of 3 to 11 years and in non-Hispanic Africa Americans than any other age group and race or origin. With the high prevalence of poverty in this demographic group, there is little or minimal access to e-cigarettes that may help in reducing the secondhand smoke exposure. The variance in prevalence in smoking, coverage of the policies that advocate for smoke-free societies, and lack of knowledge about the dangers of passive smoke highly contributed to these gaps (CDC, 2018). As such, the findings by CDC emphasize the significance of persistent considerations to intensify the coverage about smoke-free policy. This includes educating cigarette smokers about the advantages of willingly stopping smoking in their homes. Using e-cigarettes can also help in reducing the exposure of secondhand smoke in societies. With these steps, there will be a reduction of smoke exposure across all populations, especially those with a high risk of exposure.
However, the potential use of e-cigarettes could potentially complicate efforts to sustain smoke-free zones, especially schools and other areas that are considered important to public health. Majority of e-cigarette users are youth, and the use of e-cigarettes is often seen as fashionable in this demographic group. A study by Wang et al. (2017) sought to examine SHS exposure among U.S youths. The sample comprised of more than 17711 high school students drawn from the National Youth Tobacco Survey. According to the findings, at least one in four youths are exposed to SHS from e-cigarettes. The figure includes more than 4.4 million youths who do not smoke. Over 40% of the students who were exposed to second-hand aerosols (SHA) were also exposed to SHS, underscoring the potential effect of e-cigarettes on exposure to both SHA and SHS, especially in high school settings.
SHS remains a key threat to public health. It is associated with both economic and health burdens to non-smokers and imposes significant costs to society. According to the CDC, an estimated 58 million Americans were exposed to SHS between 2013 and 2014. The number includes children of ages 3 to 11. The negative health effect of SHS is significant. Since 1964, more than 2.5 million people who do not smoke have died from illnesses caused by exposure to SHS. Each year between 2005 and 2009, an estimated 34,000 deaths of non-smokers were registered as a result of heart diseases associated with exposure to SHS. Another 7300 died each year between 2005 and 2009 from lung cancer as a result of SHS.
The rise of the e-cigarette has the potential to address exposure to SHS. A review of the existing literature shows that unlike normal cigarette smoking, e-cigarettes emit fewer chemicals that may affect the health of non-smokers. It is estimated that e-cigarettes are more than ten times safer as compared to normal cigarettes. In some of the reviewed studies, the particulate matter composition of closed areas where e-cigarettes are used is almost similar to that of closed spaces where no cigarettes are used. Furthermore, they only emit small amounts of particulate matter and could, therefore, solve the problem of SHS. More importantly, they can be used as an intervention for individuals who are willing to quit smoking. Given that e-cigarettes are safer than normal cigarette smoking, they could play a key role in reducing SHS and its burden to non-smokers.
However, the perceived advantages do not mean that e-cigarettes are the solution to the tobacco epidemic. The studies reviewed indicate there are important ethical issues that may arise from the use of e-cigarettes. First, there is a probability of e-cigarettes acting as a gateway to cigarette smoking, thus eroding the progress that has been made in reducing the use of tobacco and its products. Second, there is the problem of normalization of tobacco use. Economic models show that when there are interventions to mitigate risks, the probability of the public engaging in risky behavior increases. Thus, with safer tobacco products, there is a risk that the number of users of tobacco products may increase. This is illustrated by an increase in the number of youths who smoke e-cigarettes and who are at risk of progressing to cigarette smoking. Furthermore, the pervasive use of e-cigarettes may create a societal or cultural perception that the use of tobacco products is normal and does not pose a threat to public health. Given the potential negative effects of e-cigarettes, this paper concludes that e-cigarettes are only a short term solution to SHS until further studies establish that it is safe and does not lead to the negative health effects associated with cigarette smoking, such as cancer and cardiovascular disorders.