E-cigarettes – An Alternative to the Dangers of Traditional Cigarette Smoking or Just a Toxic Trend?
E-cigarettes – An Alternative to the Dangers of Traditional Cigarette Smoking or Just a Toxic New Trend?
“It’s okay, it’s just a vape,” my patient explained defensively after rummaging through the contents of her purse to produce a medication list, having unintentionally set aside a thin, cylindrical-shaped metal object. This, of course, is after she had answered all of my smoking screening questions negatively. This was not only a reminder to me that I needed to update my line of questioning, but that I needed to be a better-informed clinician when it comes to educating my patients about smoking in any form.
We can probably all agree that traditional, tobacco-containing cigarettes are unhealthy. According to the CDC’s Office on Smoking and Health,“tobacco is the leading cause of preventable disease, disability, and death in the United States.” They estimate that approximately 500,000 Americans die annually as a result of smoking/2nd hand smoke exposure.1,2 Consequentially, this high morbidity and mortality is also a major contributor to the escalating costs of healthcare.2 Unfortunately, government initiatives, advertising campaigns, and new drugs targeting smoking cessation have all been unsuccessful at reversing this tragic trend. So when “e-cigs,” also known as “vapes,” “vape pens,” “e-hookahs,” and “electronic nicotine delivery systems” became popularized, many hailed them as a “healthy” alternative to smoking. But what does the evidence say? Let’s break down the research.
Presence of nicotine
Most e-cigarettes still contain nicotine, which is the same highly addictive component found in regular cigarettes. The CDC cites the U.S. Surgeon General, who recognized in 2010 that nicotine is “as addictive as cocaine or heroin.”3 Nicotine is detrimental to almost all organ systems, with effects such as increased blood pressure and heart rate, reduced blood flow to the arteries of the heart, damage to lung tissue and decrease of lung function, development of acid reflux, and the destruction of neurons. In high doses, nicotine is toxic and can even lead to coma and death. There is also a body of growing evidence that it may lead to increased cancer risk due to proinflammatory effects and interactions with the immune system. Still not convinced? Nicotine was utilized in the past as an insecticide.2,4 So while it is important to note that some studies have shown that e-cigarette users may receive less exposure to nicotine (and other chemicals) than traditional cigarette smokers, there are still definite established health risks.5
What if your product says that it contains “very low levels” of nicotine or does not contain nicotine at all? While this may be true in some cases, just be wary – there is a lack of enforced regulatory standards, and therefore labeled nicotine levels in e-cigarettes have been found to be inaccurate.6
Presence of other chemicals
According to the American Lung Association, there are approximately 600 ingredients in cigarettes, and when burned, a combination of up to 7,000 chemicals/metabolites.7 These can include, but are certainly not limited to the following: formaldehyde, arsenic, methanol, diacetyl, and heavy metals (cadmium, nickel, tin, and lead).3,8,9 Many of these ingredients are not only damaging to the body’s tissues, but are carcinogenic (cancer-causing). As aforementioned, it is important to note that e-cigarettes may be preferable to traditional cigarettes because they typically contain less dangerous chemicals.3,10 In keeping with this, an expert committee of the National Academy of Sciences, Engineering, and Medicine asserted that substitution of e-cigarettes for traditional cigarettes does reduce users’ exposure to toxins and carcinogens.11 However, there are still varying perspectives about the extent of the advantage of e-cigarettes versus traditional cigarettes. For example, a study comparing biomarkers in the blood of e-cigarette users to those in traditional cigarette smokers found similar effects on the mucus of the airways of both groups; in looking at effects on the immune system, they discovered apparent reprogramming of circulating immune cells, which was higher in e-cigarette smokers than traditional smokers. They go on to cite evidence indicating that vapor may be more harmful than traditional cigarette smoke, not less.2
Efficacy in smoking cessation
The Office on Smoking and Health states that e-cigarettes have a “potential” benefit in adults who are chronic smokers if used as a “complete substitute” for traditional cigarettes.3 This seems simple enough – take a product with more chemicals and trade it for a product with less chemicals and the smoker benefits. Unfortunately, the current body of research does not consistently support this theory, and instead seems to run the gamut. One study followed patients who were attempting to stop smoking after a hospital discharge; researchers found that 6 months later, patients who reported having utilized e-cigarettes post-discharge were less likely to have quit smoking traditional cigarettes than those who did not use e-cigarettes.12 Yet another study by Caraballo, Shafer, and Patel, et al. (2017) found that not only was there no strong evidence to suggest that e-cigarettes were effective in long-term smoking cessation, but that most smokers did not use e-cigarettes as an alternative; instead they continued smoking both traditional cigarettes and e-cigarettes.13 Landing more on middle ground, so to speak, was a recent Cochrane review, which found minimal evidence from 2 trials that electronic cigarettes were helpful as a smoking cessation strategy.14 And continuing along the spectrum, we have an even more recent study evaluating smoking abstinence after one year; this trial found that when combined with behavioral support, e-cigarettes were a more effective smoking cessation aid than other nicotine-replacement therapies.15
The youth crisis
One of the foremost concerns with the use of e-cigarettes is primary, or introductory, use of e-cigarettes.
Many individuals, notably children, who are not already established smokers, are beginning to partake in the e-cigarette trend as a new addictive habit, not as an alternative. Even worse, vaping may serve as a “gateway drug” to traditional cigarettes. In fact, the Surgeon General has issued an advisory, prioritizing this epidemic as a top concern.16 Last year alone, more than 3.6 million U.S. middle and high school students reported having used e-cigarettes within the past 30 days. That equates to 4.9% of middle school and 20.8% of high school students.17
More studies are needed to investigate both the short and long-term effects of e-cigarettes. Complicating this line of scientific inquiry is that new products continue to emerge and diversify in their list of ingredients, including not limited to THC, so it can be difficult to define the construct being studied.
While the consensus is that e-cigarettes are generally considered “safer” than traditional cigarettes, they are certainly not a “safe” product. Credible data exists to demonstrate the many adverse biological effects and disprove any misconception that they are “natural” or “healthy.” Be aware that the labeling of e-cigarettes is sometimes misleading and/or unreliable.
E-cigarettes may be a helpful adjunct in discontinuing regular cigarette smoking, but there is not enough evidence so far to make a definitive statement about its isolated ability to help people quit. Again, e-cigarettes are certainly not helpful in the cessation process if used in conjunction with traditional cigarettes or other tobacco products. If you are aware of the health risks, and you and your healthcare provider still feel that this may be a helpful tool to help end your smoking habit, then I certainly do not want to discourage you from attempting this method.
E-cigarettes are never recommended in pregnant women or adolescents, under any circumstances. Which brings me to my final point – second hand smoke is still a legitimate threat. So please keep this in mind when smoking in the close presence of others.
And please, if your medical provider forgets to ask you specifically about vaping when they are interrogating you about your medical history, please forgive their oversight and volunteer if you are using e-cigarettes…who knows, maybe you could even educate them a little.
1. CDC (2019, January 2). Smoking and tobacco use. Office of Smoking & Health, National Center for Chronic Disease Prevention & Health Promotion. Retrieved from https://www.cdc.gov/tobacco/about/osh/index.htm
2. Evans, C.M., Dickey, B., & Schwartz, D.A. (2018). E-cigarettes: mucus measurements make marks. American Journal of Respiratory & Critical Care, 197(4). https://doi.org/10.1164/rccm.201711-2157ED
3. CDC (2018, December 3). Electronic cigarettes. Office of Smoking & Health, National Center for Chronic Disease Prevention & Health Promotion. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
4. Mishra, A., Chaturvedi, P., Datta, S., Sinukumar, S., Joshi, P., & Garg, A. (2015). Harmful effects of nicotine. Indian Journal of Medical and Paediatric Oncology: Official Journal of Indian Society of Medical & Paediatric Oncology, 36(1), 24-31. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363846/
5. Goniewicz, M.L., Smith, D.M., Edwards, K.C., Blount, B.C., Caldwell, K.L., Feng, J.,…Hyland, A.J. (2018). Comparison of nicotine and toxicant exposure in users of electronic cigarettes and combustible cigarettes. JAMA Network Open, 1(8): e185937. https://doi.org/10.1001/jamanetworkopen.2018.5937
6. Goniewicz, M.L., Gupta, R., Lee, Y.H., Reinhardt, S., Kim, S., Kosmider, L., & Sobczak, A. (2015). Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the U.S., Korea, & Poland. International Journal of Drug Policy, 26(6), 583-588. https://doi.org/10.1016/j.drugpo.2015.01.020
7. American Lung Association (2015). What’s in a Cigarette? Retrieved from https://www.lung.org/stop-smoking/smoking-facts/whats-in-a-cigarette.html
8. Rubinstein, M.L., Delucchi, K., Benowitz, N.L., & Ramo, D.E. (2018). Adolescent exposure to toxic volatile organic chemicals from e-cigarettes. Pediatrics, 141(4): e20173557. https://doi.org/10.1542/peds.2017-3557
9. Sassano, M.F., Davis, E.S., Keating, J.E., Zorn, B.T., Kochar, T.K., Wolfgang, M.,…Tarran, R. (2018). Evaluation of e-liquid toxicity using an open-source high-throughput screening assay. PLOS Biology, 16(30): e2003904. https://doi.org/10.1371/journal.pbio.2003904
10. Ross, J. (2016, July 25). E-cigarettes: Good news, bad news. Harvard Health Blog. Retrieved from https://health.harvard.edu/blog/electronic-cigarettes-good-news-bad-news-2016072510010
11. Koval, R., Willett, J., & Briggs, J. (2018). Potential benefits and risks of high-nicotine e-cigarettes. JAMA, 320(14), 1429-1430.https://doi.org/10.1001/jama.2018.12328
12. Rigotti, N.A., Chang, Y., Tindle, H.A., Kalkhoran, S.M., Levy, D.E., Regan, S.,…Singer, D.E. (2018). Association of e-cigarette use with smoking cessation among smokers who plan to quit after a hospitalization: a prospective study. Annals of Internal Medicine, 168(9), 613-620. https://doi.org/10.7326/M17-2048
13. Caraballo, R.S., Shafer, P.R., Patel, D., Davis, K.C., & McAfee, T.A. (2017). Quit methods used by US adult cigarette smokers, 2014-2016. Preventing Chronic Disease, 14: 160600. http://dx.doi.org/10.5888/pcd14.160600
14. Hartmann-Boyce, J., McRobbie, H., Bullen, C., Begh, R., Stead, L.F., & Hajek, P. (2016). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2016, 9(CD010216).https://doi.org/10.1002/14651858.CD010216.pub3
15. Hajek, P., Phillips-Waller, A., Przulj, D., Pesola, F., Smith, K.M., Bisal, N.,…McRobbie, H.J. (2019). A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1808779
16. U.S. Department of Health & Human Services (2018, December 18). Surgeon general releases advisory on e-cigarette epidemic among youth. News. Retrieved from https://www.hhs.gov/about/news/2018/12/18/surgeon-general-releases-advisory-e-cigarette-epidemic-among-youth.html
17. Cullen, K.A., Ambrose, B.K., Gentzke, A.S., Apelberg, B.J. Ahmed, J., & King, B.A. (2018). Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011-2018. Morbidity & Mortality Weekly Report, 67(45), 1276-1277. https://dx.doi.org/10.15585/mmwr.mm6745a5