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The Green Smoke Discounts and Internets Growing Interest

Green Smoke discounts and E-cigarette companies advertise that their products do not produce secondhand smoke and are ecologically friendly leading companies are named Green Smoke discounts and Smoking Everywhere. However, whether these claims are accurate is unclear. We intend to examine current research on e-cigarettes, analyze their growing presence online, and discuss regulatory issues, with a focus on helping physicians advise patients on these devices.

The quest for a safer cigarette is not new. R.J. Reynolds Tobacco (Winston-Salem, North Carolina) invented the Premiere cigarette in the 1980s and the Eclipse cigarette in the 1990s, both of which vaporized nicotine with low levels of combustion in an attempt to create a less noxious product. In 1998, Brown & Williamson Tobacco (Louisville, Kentucky) applied for a patent on a nicotine-vaporization method that aimed to minimize harm to nonsmoking bystanders.

Research on e-cigarettes to date is equivocal.

In one of the first published studies, a laboratory analysis funded by RUYAN Group, investigators reported that e-cigarettes caused lower amounts of nicotine absorption than cigarettes and that their vapor contains no carbon monoxide, concluding that e-cigarettes represent "a safe alternative to smoking". However, a 2009 U.S. Food and Drug Administration (FDA) laboratory analysis of e-cigarettes reported trace amounts of the harmful solvent diethylene glycol, the presence of nicotine in a "light" e-cigarette labeled as nicotine-free, and a 2-fold variation in nicotine release by each puff. An independent study in which aerosol density varied by puff in 8 e-cigarette brands further suggested nonuniform nicotine delivery. A 2010 study supported by RUYAN Group showed that e-cigarettes reduced the desire to smoke cigarettes but not nicotine withdrawal compared with placebo. However, a study by Vansickel and colleagues found that e-cigarettes did not increase plasma nicotine concentrations and only modestly reduced the desire to smoke cigarettes. To date, prolonged smoking abstinence rates in e-cigarette users have not been evaluated. Despite the lack of smoking cessation data, a recent survey reported that the most frequently cited reason (65% of respondents) for using e-cigarettes was to quit smoking.

Interest in green smoke discounts and e-cigarettes seems to be increasing rapidly, fueled in part by the Internet. Google labels "electronic cigarettes" as a breakout term, defined as a phrase that has experienced a change in growth greater than 5000%, with a very large increase over the past 2 years. In 2009, the monthly average number of unique visitors at smoke everywhere was 250 000, dwarfing the 32 336 unique visitors of quit smoke gov, the most popular Web site on smoking cessation.

With 78% of Americans using the Internet and 60% seeking health information online, consumers are probably using the Internet as their main source of e-cigarette information. One novel approach used by e-cigarette companies is their Internet-based marketing strategy. These companies use "affiliate marketing schemes" in which product users can become distributors and earn profits from recruiting customers. In less than 5 minutes, someone can become a salesperson on commission, armed with an advertisement library of posters and pamphlets, customized business cards, and a Web forum to share strategies to maximize online presence. Podcasts advise sellers on search engine optimization, a way to increase market reach by having one's Web page appear first in Google search results searches. This advice seems to be succeeding: 8 of the top 10 results in a Google search for "electronic cigarette" link to e-cigarette shops. However, determining the actual number of e-cigarette users is elusive because companies do not release these data.

When health analysis about a product is sparse and consumers are also sellers, the potential for public and individual health harm is magnified. Affiliate marketing schemes are regulated by the Federal Trade Commission, which in 2009 set rules on Internet marketing. Before becoming an affiliate, a person agrees to not sell e-cigarettes to persons younger than 18 years or market e-cigarettes as a smoking cessation product, although e-cigarettes are advertised as a "smoking sensation" product and can be purchased from Web sites that do not verify age. To understand more about green smoke promo codes look into websites offering promo codes and coupons.

Another controversy is whether e-cigarettes can and should be regulated as drug-delivery devices or tobacco products. The FDA has warned against e-cigarette use and argued that e-cigarettes be classified as drug-delivery devices similar to nicotine inhalers. However, a judge recently granted an injunction by e-cigarette manufacturers to reject the FDA's stance that e-cigarettes are drug-delivery devices, thus preventing the FDA from banning e-cigarette imports. Although the FDA's appeal may yet result in e-cigarettes' classification as drug-delivery devices, they may eventually be classified under the new FDA tobacco jurisdiction because of their derivation from and similarity to other novel tobacco products. Some states, including New Jersey and New York, have tried to ban sales or disallow public use of e-cigarettes in accordance with existing smoking bans. Other countries, including Canada, Australia, Brazil, and Panama, have taken a more aggressive stance, banning e-cigarettes outright because of safety concerns and their unapproved regulatory status.

We contend that the e-cigarette boom presents important public health concerns on at least 3 fronts electronic cigarette. First, e-cigarettes may pose a risk as starter products for nonusers of tobacco. Although candy-flavored tobacco products and e-cigarettes were recently banned by the FDA in efforts to hinder marketing toward children, the posturing of e-cigarettes as "green" and "healthy" could deceptively lure adolescents. E-cigarettes also may represent a way for adolescents and adults to skirt smoke-free indoor air laws. Green Smoke discounts and coupon codes are available throughout the internet.

Second, potential e-cigarette toxicities exist that are not well quantified. A recent study documented more than 13 700 poisonings from tobacco ingestion among children younger than 6 years between 2006 and 2008. Similarly, a child playing with an e-cigarette could be exposed to nicotine from the device or from nicotine refill bottles vapejuice, which contain a concentrated liquid to fill e-cigarettes and can easily be ordered online. The nicotine dose that could be ingested or absorbed transdermally could induce fatal overdose in children. Finally, e-cigarettes may have other toxins, even in their exhaled secondhand vapor.

Third, little empirical research exists to determine whether e-cigarettes have potential as smoking cessation products. Aggressive affiliate marketing tactics are equally likely to dissuade smokers attempting to quit and could promote relapse to smoking. E-cigarettes may be less toxic than their paper analogues and may be developed as smoking cessation products, but evidence supporting these theories is currently lacking. We urgently need high-quality objective research to evaluate e-cigarette companies' claims about harm reduction and smoking cessation potential.

Health professionals need to monitor the biological, social, and addictive effects of e-cigarettes and be aware of their rapid dissemination online. National health surveys that track trends in tobacco use also should inquire about e-cigarette use. Although the safety and efficacy of e-cigarettes is uncertain, we believe that clearly counseling patients against e-cigarette use, as well as other tobacco use, is prudent. Meanwhile, e-cigarette salespersons have open access to the public.

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