Why e-cigarette should not be treated as a replacement for smoking: Vaping a public health concern
By: Dr Surabhi Bhati
Tags: Coronavirus, Health Effects Of Vaping, Corona, Vaping, Covid 19

Photo by Gabriel Ramos on Unsplash

Having a medical background, I often end up looking at health-related news online. If you also follow the same, you must have come across news about people getting hospitalised due to vaping related illness in the USA.

One day, while browsing through the news, Indian Government’s recent announcement to ban e-cigarettes caught my eye. Since then, I have heard, read and seen people arguing for and against the e-smoking ban.

Out of curiosity, I started researching about vaping and its effects on health. My approach of secondary research gradually shifted from reading the generic articles to the more research-based published articles along the way. This blog is my take on e-smoking and its health effects.

Before reading further, pardon me if the reading becomes little jargony from time to time. I have tried to keep it simple without medical terminology, as much as I can. Read along!

What is vaping and how it works?

Before digging deep into the harmful effects of vaping, let’s first understand how these Electronic Nicotine Delivery devices (ENDS), scientific name of e-cigarettes, work and what we inhale through them.

An electronic cigarette or ENDS is a battery-operated device used by people to inhale aerosols.

A typical e-cigarette consists of a cartridge filled with e-juice or e-liquid (which comes in various flavours), a heating element, a power source which is battery operated, and a mouthpiece to inhale the aerosol. The puffing activates the heating of the liquid, turning it into an aerosol. The aerosol is then inhaled and exhaled by the person, much like the process of smoking.

The aerosol typically contains a mixture of nicotine (not always), propylene glycol with or without glycerol, flavouring agents, and other chemicals.

E-cigarettes are available in the market in different sizes and shapes. Some look like a traditional cigarette, while others resemble a pen or a USB memory stick.

When and how did vaping begin

E-cigarettes were launched in 2007 in the USA, as a tool to help middle-aged smokers, quit smoking. At the time, it was publicized as a revolutionary product capable of controlling tobacco smoking and related diseases.

The popular belief of e-smoking being safe lead to increased popularity e-cigarettes among teenagers and youngsters in the last few years. According to the surgeon general report, e-cigarette use among middle and high school students increased by 900% from 2011 to 2015 in the USA.

Top reasons for the increased use of e smoking are,

Overall enjoyable experience of e-smoking with no unpleasant aftertaste and throat irritation (usually found in regular smoking). Availability in multiple flavours like bubblegum, fruit punch etc. The popular belief that e-cigarette help quit smoking and is safe to health.

“The report suggests 4.9 million teens were using e-cigarettes in 2018 — an increase of 1.5 million from the year before.”

What caused the concern: Recent mysterious lung illness among vapers in the USA

Impact of vaping on human health was merely a topic of academic research until recently. With a recent report of about 805* lung injuries in ten states of the United States of America, the harmful effect of vaping suddenly became mainstream. Sadly, It took us a decade to realise the harmful effects.

So, where did the health regulatory bodies go wrong? Did the government fail to identify the problems early on, or did they release an unfinished product in a hurry to the market?

I am sure the health professionals and regulatory bodies must be pondering over these questions. The aspects of medical regulations are out of the scope of my current blog, and hence I won’t be commenting on those for now.

As for the health effects of e-smoking, academic researchers were always concerned but there were no reported real-cases on e-smoking illness.

So the next logical question to ask was, were the concerns of academic researchers pointless or the health system was missing something. Then I got to know that the clinicians were missing to ask about the e-smoking habit during their preliminary examination.

Let me explain, Clinicians usually take the case history of the patient, as a part of medical examination (before diagnosis and treatment plan). During this, they ask questions related to patient’s health habits, past medical history, etc.

The connection between lung diseases and vaping established only when the clinicians started asking incoming patients with lung illness about their e-smoking habits. According to the CDC, all patients with mysterious lung disease had a history of using an e-cigarette.

Symptoms reported by the patients

The symptoms in lung injury cases due to vaping ranges from respiratory (breathing related, 98% cases) to gastrointestinal (related to stomach and intestine, 81% cases). The most commonly reported respiratory symptoms were, shortness of breath, cough and chest pain. The most common gut-related symptoms were nausea, vomiting, diarrhoea and abdominal pain.

Most of these cases also reported additional symptoms like fever with increased heart rate (heart rate 55 to 146 beats per minute) and respiratory rate (respiratory rate range, 15 to 48 breaths per minute). At least 15 of such cases also reported symptoms of ARDS (Acute Respiratory Distress Syndrome), a condition in which fluid gets accumulated in the air sacs of the lungs making breathing difficult.

The most alarming concern was the low median age of patients. The average patient’s age was 19 years (as per CDC data) with no previous significant medical history.

Analysing the health effects of vaping

Under this blog, I am going to cover two main aspects of e-cigarettes,

Health risk of e-cigarettes to users and non-users;

Efficacy of ENDS in helping smokers quit smoking and nicotine dependence;

1. Health risk of e-cigarettes to users and non-users

We have already discussed the symptoms of recent lung illness caused by e-smoking in my previous section. Under this heading, I am going to talk about the health effects of two main ingredients: nicotine and formaldehyde-containing hemicital.

Do note that nicotine is not always present in e-liquid but there are e-liquids containing nicotine available in the market. Due to its highly addictive properties and harmful effect of nicotine, I am including it in this section. Apart from this the fuming process also produces harmful chemicals. One such chemical produced in the process is formaldehyde-containing hemiacetal.

It is important to note that the amount and absorption of these toxic chemicals vary depending on, the voltage used for heating and individual’s puffing behaviour. Puffing at a higher temperature is found to be more dangerous.

“ Battery voltage & unit circuitry differences can result in considerable variability in the products’ ability to heat the solution to an aerosol and, consequently, may affect the delivery of nicotine and other constituents, and may contribute to the formation of toxicants in the emissions.” ( Electronic Nicotine Delivery System, WHO report, 2014)

1. a) Harmful effects of nicotine (in nicotine-containing e-cigarettes)

Not all e-cigarettes have nicotine and hence this section only applies to e-cigarettes with nicotine.

Nicotine exposure has long-term harmful effects on brain development both in the fetal and adolescent group. It is usually advised to not use nicotine products in children, adolescents and pregnant women. Moreover, many studies suggest that nicotine is highly addictive, and even though it is not carcinogenic, it may function as a tumour promoter.

1. b) Health effects of formaldehyde-containing hemiacetal (a degradation product of propylene glycol )

Research published in “The New England Journal of Medicine” explains the production of formaldehyde-containing hemiacetals when e-smoking.

During vaping, propylene glycol (one of the ingredients used in e-cigarettes) breaks down to produce formaldehyde. At high voltage, the formaldehyde further reacts with already present e-liquid chemicals, propylene glycol and glycerol to produce hemiacetals.

It is still unknown how this formaldehyde-containing hemicitals affect the respiratory tract, but it is marked as group 1 carcinogen by the International Agency for Research on Cancer.

The New England Journal of Medicine (Jensen RP et al. N Engl J Med 2015;372:392–394)

E-smoking became highly popular among the young population because of its marketing as a smoke cessation tool with no health hazards. The next section of my blog will highlight more on the effectiveness of ENDS product as a tool to help in quitting smoking.

2. Is vaping efficient in reducing traditional smoking?

When first launched, e-cigarettes was marketed as a tool to help smokers quit tobacco smoking. But does it help smokers in quitting smoking?

There are small scale studies suggesting e-cigarette as an effective tool to quit smoking. One such study was conducted among 886 participants, who were given a choice to use e-cigarettes or nicotine patch to help them quit smoking. The objective was to find which one is better smoking cessation tool: nicotine patch or e-cigarette.

The research revealed that the rate of quitting was 8% more in e-cigarettes users as compared to the nicotine patch users. Even though the rate of quitting traditional smoking is more in case of e-cigarette users, the rate of complete cessation was not.

The same study also that 80% of e-smokers started using e-cigarettes regularly, after quitting smoking as compared to only 9% of nicotine patch users. It concludes that e-cigarette is more addictive as compared to the nicotine patch.

The use of ENDS might help some smokers to quit, but studies suggest that for a sizeable number of smokers, ENDS use will only reduce the cigarette frequency rather than complete quitting. The users trying to quit smoking with the help of e-smoking usually end up using both e-smoking and regular cigarettes.

As for health benefits, the number of years spent on tobacco smoking is more harmful than the intensity of smoking, the dual-use of both traditional and e-cigarette smoking have much smaller beneficial effects on the overall health.

Due to the above reasons, e-cigarette is not recommended by health agencies (including FDA and WHO) as a quit-smoking tool.

My personal views on e-smoking (conclusion):

Due to lack of sufficient scientific research, recent entry of ENDS in the market, and relatively long lag time for disease onset conclusive evidence on the harmful effects of chronic e-smoking will take time and might not be available for years.

It took us decades to understand the harmful effects of tobacco smoking. Chances are if the health effects of vaping are not studied, and its use is not regulated, we will find ourselves in the same situation.

Health agencies need to plan a comprehensive, long-term study to evaluate the safe use of e-cigarette before allowing the long term use of e-cigarettes.

“We don’t really know what the effects of chronic vaping is on your lungs.”

Updating after Corona Virus Pandemic: We are on a verge of global crisis where millions of people worldwide are suffering or going to suffer from previously unknown disease/ medical condition caused by a coronavirus.

The new disease is named COVID-19, which can cause life-threating, rapidly spreading pneumonia in serious cases. The disease is more severe in people with comorbid conditions or with weakened lungs.

Here is some food for thought- “ Do you still think that vaping was OK and does not weaken your lungs?”

I hope you all are staying safe!

Citation:

List of research publications/articles, I read along the way of my research on e-smoking and its effects.