The e-cigarette dilemma

Smoke-filled bars and restaurants, airplanes and office buildings. The Marlboro man graced newspapers and magazines. Tobacco companies sponsored popular television shows, and cartoon characters promoted cigarettes in commercials.

The message in the early 1960s screamed: "Cigarettes are cool." And the nation took the bait, as about four in 10 Americans smoked.

But 50 years ago, that perception began to change. A landmark surgeon general report released Jan. 11, 1964 first documented the health consequences of smoking. The report served as the driving force behind tobacco policies and advertising restrictions.

Social norms changed as an anti-smoking grassroots movement emerged. One of the greatest public health catastrophes turned into one of the greatest successes, states a surgeon general report, "The Health Consequences of Smoking - 50 Years of Progress," released this year.

Smoking's popularity has declined over time and so have smoking violations in Carroll County Public Schools, Student Services Director Dana Falls said, attributing the decrease to tobacco education and advertising restrictions.

"I think kids don't see it as cool," he said, "and I think at one time they did."

But in recent years, other nicotine products - such as electronic cigarettes - have entered the marketplace with their potential health implications unknown.

Some young teenagers think the devices are "cool," said Bob Large, owner of Quality Vapor Source in Taneytown.

"I think it's a trend that [kids are] seeing a lot of adults have these devices," he said. "They're mechanical, they're digital. ... They're very appealing because of the technical aspect of them."

Everywhere Barbara White goes, she said, it seems someone asks her about the devices. The director of the Carroll County Health Department's cigarette restitution fund program tells them the jury is still out.

"We don't know that it's safer than using tobacco," she will say. "We don't know that it's completely safe."

The surgeon general is tasked with balancing this new vapor-producing, smokeless product with the overarching goal of becoming a smoke-free society.

Some say the device has helped them quit smoking, and the 2014 surgeon general report states nicotine-delivery devices that better substitute for cigarettes might help with the goal of becoming a smokeless society. But public health officials are quick to note there's a lack of scientific research on e-cigarettes as an effective smoking cessation tool.

The products contain nicotine, which is highly addictive. It activates multiple biologic pathways pertaining to fetal growth and development, immune function, the cardiovascular system, the central nervous system and more, according to the surgeon general's 2014 report.

"Nicotine is highly toxic," White said, "so could you imagine if your kid or your dog got a hold of one of those little bottles?"

And more Americans are calling poison centers with concerns about e-cigarette liquid, according to a U.S. Centers for Disease Control and Prevention report released this month.

The number of calls increased from one per month in September 2010 to 215 in February. About 51 percent of those calls involve children younger than the age of 5.

"This report raises another red flag about e-cigarettes - the liquid nicotine used in e-cigarettes can be hazardous," CDC Director Tom Frieden said in a statement. "Use of these products is skyrocketing, and these poisonings will continue. E-cigarette liquids as currently sold are a threat to small children because they are not required to be childproof, and they come in candy and fruit flavors that are appealing to children."

Calls to the Maryland Poison Center about e-cigarette nicotine or the device or cartridge increased from 1 in 2010 to 23 in 2013. Six calls from 2010 to 2013 came from Carroll County. Roughly 52 percent of all 46 calls involved children younger than 5 years old.

The reporting system is voluntary, doesn't include statistics from Prince George's or Montgomery counties and is based on the origin of the call, according to Bruce Anderson, director of operations at the poison center, a service program of the University of Maryland School of Pharmacy.

The calls have generally resulted in favorable outcomes, but that doesn't mean the center believes the substance is benign, according to Anderson. The high concentrations of nicotine in some devices may result in nausea, vomiting and other side effects.

Yet, some residents said the battery-powered products are less harmful to them than their old vice.

Russell Keeney, of Westminster, has weaned himself off cigars and e-liquids with high nicotine concentrations. He inhales vapor with 12 mg of nicotine, hoping to shortly go down to 6 mg, one of the lowest levels.

Officials are trying to decide how to juggle the device's potential harms with its possible benefits. It's a complex issue, as products are rapidly entering the marketplace from companies with "little or no experience in developing and marketing traditional tobacco products," the surgeon general's 2014 report states.

It cites a plethora of persisting questions: How should the potential toxicity and health effects of the more than 250 e-cigarette brands be measured? What are the reduced risks of using e-cigarettes versus traditional cigarettes? How should the products' advertising and marketing be regulated?

The U.S. Food and Drug Administration intends to propose regulations but has not yet publicly released such rules. The agency could not comment on a time frame, but stated the proposal has been sent to a division within the Office of Management and Budget, according to FDA spokeswoman Jenny Haliski.

"Further research is needed to assess the potential public health benefits and risks of electronic cigarettes and other novel tobacco products," Haliski wrote in an email.

When cigarettes first hit the marketplace, the harms of smoking eluded public health officials. Since then, nicotine has been proven to be highly addictive. But as far as nicotine-laced e-liquids go, there's a lack of research documenting just how it may impact the body.

"Definitely we don't know what the long-term effects of the e-cigarette are," White said, "and that's something that may take a few years to figure out."