Hitting the Books: The continuing controversies surrounding e-cig safety

Though more than a billion people worldwide still smoke cigarettes, folks who are looking to kick the habit have an ever-widening wide array of modern assistive techniques and technologies at their disposal. However, among the talk therapies and transdermal nicotine patches, no smoking cessation aid has perhaps had more of an impact in pop and mainstream culture than e-cigarettes. In Viral BS: Medical Myths and Why We Fall for Them, Dr. Seema Yasmin examines controversies surrounding the tobacco replacement technology — as well as a host of other pieces of “common” medical knowledge. In the excerpt below, Yasmon recalls the months of 2019 when vaping briefly took a turn for the deadly.

Viral BS (Johns Hopkins University)

Excerpted from Viral BS: Medical Myths and Why We Fall For Them by Dr. Seema Yasmin, published by Johns Hopkins University Press. Copyright © 2021. Used by permission. All rights reserved.

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In the spring of 2019, young people, mostly young men in Illinois and Wisconsin, began to fall sick with a strange lung disease. They coughed, struggled to catch their breath, and some ended up on ventilators inside intensive care units. By August, a young man died of the lung disease in Illinois. Another died from the same condition in Oregon. A boy died in New York in October, becoming the first teenager to die from the mysterious disease.

Public health experts interviewed the cluster of sick men and the families of those who had died and discovered they had something in common: they smoked cigarettes. By November 2019, 2,290 people had fallen sick with the lung disease, and nearly fifty people had died across twenty-five states and the District of Columbia. The Centers for Disease Control and Prevention labeled the condition EVALI, or e-cigarette or vaping product use–associated lung injury.

Investigators seeking clues found that ingredients in the liquids that were being smoked in e-cigarettes could be the culprit. But this discovery sparked a massive debate. Around the world, medical experts have been in disagreement over the safety of e-cigarettes. Some doctors hail them as the best tool to help smokers give up cigarettes, while some health agencies have declared e-cigarettes responsible for creating a new generation of nicotine addicts. England’s leading public health agency, Public Health England, recommends that doctors should be allowed to prescribe e-cigarettes for smoking cessation. Some British politicians have called for e-cigarette laws to be relaxed.

The World Health Organization has argued that too little is known about the long-term effects of using e-cigarettes, that the nicotine in them is addictive, and that some flavorings in e-cigarettes can cause irritation and inflammation of the airways. In 2019, San Francisco became the first US city to ban the sale of e-cigarettes, with city officials declaring an “abdication of responsibility” by the Food and Drug Administration in regulating the products. In September of 2019, as the outbreak of EVALI continued to grow, the FDA conducted its own investigation and found vitamin E acetate in the cannabis vaping products of nearly every person sick with EVALI in New York. Vitamin E is safe to ingest or apply to the skin and is found in food and lotions, but it is not safe to inhale. The FDA said it was being added as a thickening agent and to possibly increase levels of THC, the main psychogenic compound in cannabis. Two months after the FDA’s discovery, the CDC announced a breakthrough. It found vitamin E acetate in the lungs of twenty-nine people with EVALI.

Electronic cigarettes, or e-cigarettes, also known as vaporizers and vape pens, are battery-powered smoking devices that contain a vaporizer, which heats up the liquid in a cartridge. That liquid usually contains nicotine, flavorings, and other additives. The heating element in most e-cigarettes is activated by inhaling, while others have a manual switch.

There are two main types of e-cigarettes, open system or open tanks and closed system or closed tanks. In an open tank, the liquid that is vaporized can be manually refilled, and there’s usually a removable mouthpiece. In a closed tank e-cigarette, ready-made refills are screwed directly onto the battery. Open tank e-cigarettes are the most popular type of e-cigarette.

In the United States, the FDA says there’s an “epidemic” of vaping among teenagers and e-cigarette manufacturers aren’t doing enough to combat underage use of their products. Some public health experts in the United States have called e-cigarettes an emerging public health threat, quickly undoing decades of antismoking campaigning.

Why can’t everyone agree? For one, e-cigarettes have only been around since 2003, when the first commercially successful e-cigarette was created by Hon Lik, a Chinese pharmacist and smoker. It’s said that Lik invented the electronic cigarette after his father—a heavy smoker, like Lik—died from lung cancer. Lik may have been inspired by Herbert Gilbert, who patented a “smokeless, non-tobacco cigarette” four decades earlier in 1965.

While the number of cigarette consumers is steadily decreasing—down from 1.14 billion in 2000 to 1.1 billion people globally, according to market research group, Euromonitor—the use of e-cigarettes is rising dramatically.

The number of e-cigarette smokers has increased fivefold in a five-year period, going up from 7 million in 2011 to 35 million in 2016, according to Euromonitor. The company predicts that 55 million people will be smoking e-cigarettes by 2021.

The industry was worth an estimated $22.6 billion globally in 2018, compared to $4.2 billion in 2013, with the United Kingdom, Japan, and the United States establishing themselves as the biggest markets for vaping products. In these three countries, e-cigarette users spent more than $16 billion on vaping products in 2016.

E-cigarettes have overtaken regular cigarettes to become the most popular tobacco product for American teenagers. One in five 18- to 24-year-olds in the United States has used an e-cigarette, according to the CDC.

Cigarettes contain thousands of compounds, at least seventy of which are known carcinogens. They also contain carbon monoxide, arsenic, and other poisons. E-cigarettes, on the other hand, contain far fewer compounds overall, perhaps hundreds of chemicals instead of the thousands found in cigarettes. The main ingredients of vaping fluid are glycerol and propylene glycol, which many say are harmless when inhaled. But employees of theaters and movie sets who use these chemicals to create mist and fog special effects, have reported breathing problems, perhaps linked to long-term exposure of propylene glycol.

In studies, some e-cigarette vapor has been found to contain very low levels of nitrosamines, which have been linked to cancer. Other studies have shown that the vapor contains toxic chemicals, including acetaldehyde and formaldehyde and some flavorings, especially cinnamon, butter, and vanilla, contain free radicals, which can damage DNA. The relative novelty of e-cigarettes means a lack of long-term safety data. For this reason, some scientists have called out politicians and public health agencies advocating for the expanded use of e-cigarettes.

In a 2018 report, Public Health England said it was plausible that e-cigarettes were responsible for the highest ever rate of people who had successfully given up smoking cigarettes in England. But there’s conflicting evidence about the effectiveness of e-cigarettes as a tool for smoking cessation.

In the same report, Public Health England goes on to say that of seven meta-analyses of smoking cessation, two found a positive effect of e-cigarettes on quitting smoking, four were inconclusive, and one found a negative effect. In a 2018 study of more than 6,000 smokers, researchers at the University of Pennsylvania found e-cigarettes were not useful in helping cigarette smokers kick the habit. (Cash incentives were.)

There’s a widespread belief among e-cigarette users that vaping is safe and can help with quitting regular cigarettes. In a 2016 report by Ernst & Young, with Nicoventures, a start-up of British American Tobacco, research conducted in seven European and Asian countries showed the most common reason for smoking e-cigarettes was that they were considered “less harmful than regular cigarettes.” Almost half of all regular users said they were using e-cigarettes to give up smoking cigarettes.

But in the United States, where e-cigarette use has increased 900 percent since 2011 among high schoolers and where nearly 6 percent of middle school students say they have smoked an e-cigarette in the last year, public health officials say vaping is introducing more young people to the idea of smoking and could lead to cigarette use.

In a 2016 report, US Surgeon General Dr. Vivek Murthy, said young people are at highest risk of becoming addicted to the nicotine in e-cigarettes. Nicotine impacts brain development, which continues until people are in their mid-twenties. Nicotine can affect the prefrontal cortex, a part of the brain that is the last to mature. Studies have shown that exposure to nicotine during the teenage years increases a person’s risk of developing psychiatric illnesses and attention deficit disorders.

Some scientists are worried that teens who smoke e-cigarettes are more likely to go on to smoke regular cigarettes. Scientists at the University of Hawaii found e-cigarettes promoted cigarette smoking among young people. The researchers interviewed more than 2,000 high school students in 2013 and again a year later. About a third of those students said they had tried an e-cigarette by the time they were first interviewed. A year later, students who had previously smoked e-cigarettes were about three times more likely to have tried a regular cigarette, compared with those who had not used e-cigarettes.

In Britain, the Royal College of Physicians (RCP) says smokers should be given e-cigarettes to help them give up smoking regular cigarettes. In a report published in 2016, the United Kingdom’s leading medical body said e-cigarettes are not a gateway to smoking and should be used as a smoking cessation aid.

In 2014, a study in Britain found that those who used e-cigarettes were 60 percent more likely to be successful in giving up cigarettes than those who went cold turkey or used nicotine patches and gum. But some experts say it’s too soon to tell if e-cigarettes help people quit smoking, although the evidence so far has swayed the RCP and Public Health England. E-cigarettes have now outpaced nicotine gum and patches to become the most popular tool for smoking cessation in Britain.

The FDA has not licensed e-cigarettes as a tool for smoking cessation. In fact, the agency offers a warning about the risks posed by e-cigarettes. In 2009, the FDA analyzed the liquid contents in two leading brands of e-cigarettes. It found them to contain chemicals that can cause cancer, including nitrosamines, and a toxic chemical found in antifreeze.

In 2018, the FDA found prescription medications inside vaping fluid. Erectile dysfunction drugs, Viagra and Cialis, which should be available only with a prescription, were discovered inside e-cigarette liquids made by the Chinese e-cigarette maker, HelloCig Electronic Technology. The medicines could dangerously lower blood pressure, the agency said.

There’s also a threat of injury when the battery inside an e-cigarette overheats. More than two dozen people were injured by exploding e-cigarettes from 2009 to 2014, according to the US Fire Administration. Doctors say those injured suffer flame burns, chemical burns, and blast injuries.

Public health experts continue to disagree about the safety of e-cigarettes, leaving the more than 35 million people who use them in the middle of a heated debate. They may be healthier than smoking cigarettes, but that doesn’t mean they are harmless.

By February 2020, the outbreak of EVALI had spread to every state in the United States, and the CDC said it would officially count only those people who were sick enough to be hospitalized with EVALI or die from the disease. By that count, the CDC reported nearly 3,000 people who had been hospitalized and sixty-eight deaths. But federal authorities have been slow to regulate the products; in fact it was only in 2016 that the FDA was given regulatory powers over e-cigarettes. In the absence of federal leadership, the United States has a patchwork of vaping regulations that vary massively by state, leaving individual consumers to figure out what is safe and what is not.