Tobacco continues to be big business — a $35 billion market — but electronic cigarettes are burning away at the market share. E-cigarettes are booming. New technologies claim reduced adverse health effects compared with tobacco smoking. These products, however, are not without harm or risk and carry with them an increased likelihood that nonsmokers will begin to smoke.

E-cigarettes were designed by a Chinese pharmacist in 2003. They use heat or ultrasonic technology to vaporize a propylene-glycol or glycerin-based liquid solution into an aerosol mist much like a humidifier. They are designed to look similar to real cigarettes and are advertised as delivering a "smoking experience" at a more affordable price without the adverse health effects commonly associated with smoking. "E-liquid" comes in different strengths, from zero to extra-strength nicotine, and come in an attractive variety of flavors.

The use of e-cigarettes in the U.S. has risen dramatically since becoming available in 2008. Eight percent of the general population and 30 percent of smokers tried them by 2012 and cultivated a $1.5 billion market. Traditional smoking rates are continuing to decline while e-cigarette use is exploding.

Most states, including Hawaii, prohibit sales of e-cigarettes to minors. There are very real concerns that these devices might encourage nonsmokers, particularly children, to start smoking and develop nicotine addiction. A Hawaii study of 1,941 high school students (average age of 14.6) were asked about risky behaviors. The results showed that 17 percent of the teens used e-cigarettes only, 3 percent used cigarettes only, 12 percent used both and 68 percent used neither. Those who used only e-cigarettes were considered as intermediate in risk status, which raises the possibility that e-cigarettes appeal to medium-risk adolescents, who otherwise would be less susceptible to tobacco product use.

Tobacco use is responsible for nearly 1 in 5 deaths and accounts for at least 30 percent of all cancer deaths. About 70 percent and 85 percent of lung cancer deaths among women and men, respectively, are the result of tobacco use. Tobacco products also can cause several other types of cancer and a sixfold increase in heart attacks compared with nonsmokers. Although the risk of coronary artery disease decreases rapidly after smoking cessation, the risk of lung cancer decreases more slowly. Lung cancer is without a doubt the most common cause of cancer death worldwide and results in more cancer-related deaths then prostate, breast and pancreatic combined. All of the tobacco-related adverse health events add up to health care dollars. The annual health care cost in Hawaii directly caused by smoking is estimated at $336 million.

Only 10 to 20 percent of smokers will ever try to quit, and 70 to 80 percent of those people will relapse. In health care, providers fail 9 times out of 10 at prompting and supporting successful quitting. Although often marketed as a smoking cessation tool, e-cigarettes are not approved by the U.S. Food and Drug Administration as a smoking cessation therapy.

E-cigarettes may be less addictive, reduce nicotine withdrawal, are associated with negligible secondhand smoke exposure, and better mimic the "hand-to-mouth" experience compared with other types of nicotine replacement therapies. However, the jury is still out with limited long-term evidence supporting the arguments that they aid in smoking cessation.

Despite potential benefits, toxins and carcinogens are still present, the amount of nicotine delivery is inconsistent, the potential negative health effects are still unclear, there remains concern regarding secondhand vapor exposure, and the lack of regulation makes it difficult to determine safety risks.

In December 2013 the U.S. Preventive Services Task Force recommended annual screening for lung cancer with low-dose CT imaging in adults age 55 to 80 who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening can be discontinued after 15 years of not smoking. Pack years are calculated by multiplying the number of packs (20 cigarettes per pack) of cigarettes smoked per day by the number of years smoked.

Some of the limitations to screening include missing patients who do not meet these criteria, imaging that reveals noncancerous nodules resulting in overtreatment and false positive findings, and screening not being a substitute for smoking cessation.

While e-cigarettes might reduce smoking rates and adverse health risks, we simply do not know for sure until these products are more properly researched and regulated. There are distinct concerns about e-cigarettes being used as a recruitment tool for adolescents and adults who would have not otherwise used tobacco products. To reduce the risk of tobacco-related adverse health effects, the primary focus must be to discourage individuals from smoking in the first place and getting those who smoke to quit. It is also essential to screen for lung cancer in those with a significant smoking history.

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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.