Electronic cigarette (e-cig) is a new phenomenon in the world including Indonesia. Its presence isconsidered by some as an alternative for overcoming dependency on cigarette without reducing the enjoyment and sensation of smoking tobacco cigarette itself. On the other hand, e-cigarette is also criticized for its safety factor and health impact on its users. E-cigarette is a smoking simulation device through inhalation of nicotine vapor, propylene glycol, glycerine, and flavorings. Several studies on the chemical content of liquid and vapor produced by e-cig found small amount of contaminants but at a level far below conventional cigarette smoke. More than 50 health researchers in the world have sent a letter to World Health Organization (WHO), stating that there is a huge potential in tobacco harm reduction products (i.e. e-cig) for reducing disease risk related to cigarette, making it the biggest health innovation in the 21st century with a potential to save hundreds of millions of human lives. From this perspective, e-cig seems to be a safer alternative for smokers who cannot stop nicotine addiction, and can be a “framework” in the effort to reduce cigarette danger without eliminating smoking habit. Similar media have proven to be successful in the past, such as the use of disposable needle for drug users and safe sex promotion through condom protection in preventing the spread of HIV infection. E-cig seems capable of substituting the physical appearance of cigarette and smoking activity, especially the behavior closely related to sense stimulation. Therefore, many health experts and anti-tobacco activists suggest that e-cig is effective in reducing tobacco consumption, and it is efficient as a long-term substitute for conventional tobacco.

A research report on the safety and risk of e-cig vapor chemical content stated that no presence of acrolein, phenol (mucosa irritant), and PAH (carcinogenic substance) was found; however, traces of aceltadehyde and formaldehyde (carcinogenic substance and mucosa and eye irritant) were found in small amounts, as well as some traces of TSNAs/Tobacco-specific nitrosamines (NNN, NNK, and NAT, a substance said to be carcinogenic originated from tobacco nicotine) but the content is on par with the content in NRT (nicotine replacement theraphy), carbon monoxide, VOC (volatile organic compounds, which irritates the mucosa and can cause headache and nausea), diethylene glycol, tandalafil, rimonambant, and cadmium, nickel, and lead metals (Laugesen et al. 2008 and 2009; Hadwiger et al. 2010; Cahn and Siegel 2011; Pellegrino et al. 2012; Kim and Shin 2013; Etter et al. 2013; Goniewicz et al. 2013; William et al. 2013; Burstyn 2014). Babaian et al. in 2012 studied the impact of e-cig vapor exposure on indoor air quality compared to tobacco smoke. In terms of pollutant concentration analysis, they observed that the vapor of e-liquid is significantly lower than cigarette smoke, due to the absence of burning process in e-cig then the e-cig vapor particle count is lower than tobacco cigarette smoke. They concluded that e-cig vapor has minimal impact on indoor air quality, and therefore no risk to health was observed based on the vapor chemical compound analysis.

Toxicology study of e-cig vapor and e-liquid are mostly done through cytotoxicity tests on cell culture (invitro), with the conclusion that parent cell culture/stem cells are more sensitive to the effects of e-liquid (Bahl et al 2012),  the cytotoxicity level is lower than cigarette smoke which was observed to be very toxic (cytotoxicity 795%) even after dilution to 25% (Romagna et al 2013) and 12.5% (Farsalinos et al. 2013),  and the cytotoxic effect is 400 times lower than the level allowed by US EPA, 2000 (Behar et al. 2014). Some animal tests have been conducted to evaluate the potential humectant effect in e-liquids such as propylene glycol and glycerol which may enter by e-cig vapor inhalation on rats and dogs (Werley et al. 2011), and on Sprague-Dawley rats to look for traces of squamous metaplasia/change in epiglottis epithelium and lung abnormality (Renne et al.1992).

Clinical study reports on e-cig may provide a more informative result like the research report by Polosa et al. 2013 that studied smokers for 24 months after intervention 6 months earlier with e-cig, moderate symptoms were observed such as mouth and throat irritation and dry cough. Farsalinos et al 2013, evaluated retrospectively research subjects consisting of 111 e-cig users who had stopped smoking. Sore throat and cough were the most reported side effects complaints. Flouris et al. in 2012 observed that smoking a cigarette caused rapid increase of white blood cells, neutrophil, and lymphocyte (an indication parameter of acute inflammation condition), but this was not observed in e-cig usage. Only two randomized controlled trials scrutinized e-cig safety which found no serious adverse effect on health (Caponetto et al 2013 and Bullen et al 2013). Farsalinos et al 2012 evaluated the effect of e-cig use compared to cigarette on hemodynamics and ventricular functions, and it was observed that giving e-cig to volunteers with a little above-average blood pressure after consuming cigarettes caused their systolic and diastolic blood pressure and their heart pressure dropped significantly due to the low nicotine levels in e-cig. In 2013 Farsalinos et al evaluated the acute effect of cigarette and e-cig on coronary flow, and it was observed that cigarette is closely related to the decline in absorption of velocity reserve flow from arteria Coronaria by 16% and the increase of flow obstruction by 19%, but e-cig did not cause these. Similarly, the level of carboxyhemoglobins was observed to be higher in smokers than e-cig users.

From the latest e-cig safety and risk article study above, it can be concluded that the use of e-cig is a far less harmful substitute to tobacco cigarette. The absence of tobacco and burning process in e-cig usage prevents e-cig users from exposure to toxic cigarette emission, and from contamination of toxic substances resulting from tobacco processing. Although some toxic chemicals are contained in e-cig VAPOR, they are at a far lower concentration than cigarette SMOKE, even the level of nitrosamines contained in e-cig vapor is on par with pharmaceutical nicotine products (nicotine gum/patches). Future development of e-cig device should be conducted with regard to the design and atomizer/cartomizer materials in order to further reduce the danger and at the same time to improve the efficiency of nicotine delivery, and also with regard to the safety of e-cig flavoring liquid (e-juice/e-liquid) to control the relative risks of the compounds that they contain.

Indonesia as a country with high level of cigarette consumption should consider the use of e-cig as a substitute to conventional cigarette in order to control tobacco consumption. The government should not ignore and instead should utilize e-cig potential as a tobacco harm reduction product in people’s health policy through tight regulations to prevent the penetration of e-cig usage by children and teens, and so that manufacturers can guarantee the quality of the materials used as well as product efficiency and safety tests. Therefore, standardization of e-cig device and the nicotine content in e-liquid will contribute to potential health benefits, namely minimization of danger and effects on the users.

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