Is Vaping Safe?

I have never been a cigarette smoker, but they have impacted my life significantly. My maternal grandfather died from emphysema when I was an infant after roughly 40 years of smoking unfiltered Camels. My father smoked and tried to quit for many years unsuccessfully, and died from a heart attack at the age of 57. My stepfather smoked, and died of lung cancer that had spread to his brain at 55. Of all the temptations and peer pressures that are faced as an adolescent, smoking was something that, fortunately, no one ever tried to get me to start. When one of my friends that smoked asked me if I smoked and I said no, they always said “good…. don’t”.

According to the American Cancer Society, in 2012 roughly 18% of the U.S. population smoked cigarettes, which is about 42 million – a little less than 1 in every 5 people. The Center for Disease Control (CDC) estimates that worldwide, 6 million people die each year from smoking and that on average, smokers die 10 years earlier than nonsmokers. Smoking is linked to a host of health problems, including lung cancer, coronary artery disease, heart disease, emphysema, stroke, gum disease, and oral cancer.

Nicotine is the addictive substance that drives people to keep smoking. It is what makes smoking very difficult to stop once it is started. It creates a feeling of euphoria and improves concentration and alertness (similar to caffeine), and while it potentially has use as a medicine for treatment of a few diseases, it is a potential toxin. Tobacco products contain chemicals called tobacco specific nitrosamines (TSNAs) which are known carcinogens (cancer causing agents).

It is well known how bad cigarette smoking is for you, and it is also very hard to quit smoking. Various alternatives to “cold turkey” exist such as nicotine gum, nicotine patches, and medications (Chantix® and Zyban®, also known by its generic name, bupropion) – all with varying degrees of success. There are some people that suggest smokeless tobacco (such as dipping tobacco or snuff) as a less harmful alternative, but this is a very controversial topic because oral tobacco still contains the TSNAs that cause cancer. Smokeless tobacco also is, on average, less socially acceptable in the United States than cigarettes, and because there are less people using smokeless tobacco¹ (9 million people in the U.S. use smokeless tobacco compared to 42 million cigarette smokers), its effects in comparison to smoking is less well understood. Use of smokeless tobacco in India has been shown to be linked to a higher incidence of oral cancer, however their type of oral tobacco (betel quid – a mixture of betel leaf, areca nut, and slaked lime to which tobacco is often added) is different from the common types of dip/chew that is used in the U.S. Smokeless tobacco can cause tissue changes in the mouth that can be pre-cancerous, and causes staining of the teeth and gum recession (which if severe enough, can lead to tooth loss).

Electronic cigarettes (or e-cigs) are a relatively new nicotine delivery system. It replicates the hand-to-mouth repetitive motion and visual cue of smoke-like vapor of cigarettes, and can be used in many “smoke-free” places. It is a very accessible product available online, at mall kiosks, retail outlets, etc. They also have a perceived potential for harm reduction – many people may think they are puffing on harmless water vapor. However this is still too new of a product to say what the long term health effects of e-cigs are. And it may be many years (possibly decades) before we do know just how they affect us.

I recently saw Eddie Van Halen, one of the greatest living guitarists in the world, vaping in a photo for a magazine interview. Van Halen was a smoker for many years and has had many surgeries due to tongue cancer (reportedly originally found by his dentist). He now speaks with a slight lisp. After seeing him vaping, I really wondered just how much better that is for him than smoking.

So what do we really know about electronic cigarettes and the effects of vaping? I have done my best to find out. I have researched as many sources as I can, including published information from the CDC, Food and Drug Administration (FDA), American Dental Association (ADA), and publications from various research journals on the subject. You must keep in mind that, even when dealing with scientific data, the truth can be hard to find. Some studies receive funding from companies that produce the products that are being tested (like oral tobacco or e-cigs), so it is hard to know if it is without bias. Other publications from organizations that promote the complete elimination of all tobacco products may be hesitant to say that e-cigs are less bad than smoking, preferring to say that quitting use of nicotine entirely is the only way. All that one can do is research as many reputable sources as possible, use common sense, and make a judgment for yourself.

Electronic cigarettes consist of a lithium ion battery, electronic components, an atomizer, and a cartridge that holds a liquid solution. The common liquid solution components are: water, propylene glycol, vegetable glycerin, flavorings, and nicotine. Propylene glycol and vegetable glycerin are carriers in food products, food coloring, and commonly used as an additive in medications. These ingredients hold the nicotine and flavor in suspension. Exposure to propylene glycol can cause eye and respiratory irritation; prolonged or repeated inhalation in industrial settings may effect the central nervous system, behavior, or the spleen. When heated and vaporized, propylene glycol can form propylene oxide, a carcinogen, and glycerol forms acrolein, which can cause upper respiratory tract infection.

E-cig vapor contains a number of potentially toxic compounds. Formaldehyde, acetaldehyde, and acrolein (potentially toxic chemicals) have been found in 12 brands of e-cigarettes, but at much lower levels than in cigarette smoke.

A review conducted of the results of 16 lab tests of e-cig liquid found TSNAs in two of the studies, but at trace (very low) levels similar to those found in a nicotine patch, which is about 0.07-0.2% the amount found in cigarettes.

Cadmium, nickel, lead, and other metals have been detected in e-cig vapor, but in trace levels only. A study evaluating the amounts of these levels found them to be at levels lower than permissible daily exposure as defined by OSHA and similar organizations. The amounts of these metals were determined by the study to not be a significant health concern for smokers switching to e-cig use, but are an unnecessary source of exposure for those who have never smoked. Another study found that the e-cig vapor they studied contained particles of tin, silver, iron, nickel, and silicate, as well as nanoparticles, many of which are known to cause respiratory disease. Some of these were in concentrations higher than that found in tobacco smoke.

At least one study found that e-cig vapor contains ultra-fine particles that can inflame the lungs of bystanders as well as users. This inflammation can trigger a heart attack.

A concern that is separate from the effect of the vapor is the danger in the liquid, or e-juice, itself. The concentrated nicotine juice is toxic, especially to small children. The FDA reports a surge in cases of poisoning from children getting their hands on the e-cig liquid containers and drinking the juice. In December 2014, ABC News reported a death of a one-year-old child in Fort Plain, New York after ingesting e-juice. At least one study has found some e-juice to be cytotoxic, meaning toxic to human cells.

Electronic cigarettes have been shown in some studies to be effective in helping smokers quit smoking cigarettes or at least reduce their cigarette per day usage. However, some people see the e-cig as a gateway for others who have not smoked before.

Another issue is that e-cigs are not currently regulated by the FDA. This is because e-cigs generally do not market themselves as a drug that has any therapeutic effect. If an electronic cigarette claims to be beneficial to help people stop smoking, then the FDA would be able to regulate them (they would have control over how they are manufactured and be able to give the general public more information on what is in them). The FDA is currently trying to extend their control to include electronic cigarettes, but as of July 2015 this issue has not been resolved – e-cig manufacturing is still largely unregulated.

So what does this all mean? What do we know for sure? I’ll try to summarize:

– Electronic cigarettes, and the vapor they produce, have less chemicals in them than cigarettes and cigarette smoke

– E-cig fluid contains food additives approved for consumption by the FDA, but propylene glycol has not been tested as a warmed inhalant. We don’t know how breathing it into our lungs affects us over the course of many years

– Using e-cigs can expose you to nicotine (an addictive substance), various metals and other small particles that can harm your lungs, and some of the same cancer-causing chemicals that are found in cigarettes (even if they are at much lower levels)

– Drinking the e-cig liquid can be poisonous, and drinking enough of it can be fatal

– The current body of evidence is insufficient to conclude that electronic cigarettes are safe in absolute terms

Is vaping safe? It is quite possible that e-cigs are not as bad for you as conventional cigarettes, but it is still the “Wild West” in terms of e-cig production, distribution, and medical knowledge of the effects they have on the body. And it will likely take decades to fully obtain that information. Until then, health care professionals will likely be very reluctant to recommend electronic cigarettes.

Marc

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 1 – According to a 2013 Survey by the U.S. Substance Abuse and Mental Health Administration