Electronic Cigarettes (Vaping)

What is a “regular” cigarette?

Before I start talking about electronic cigarettes, let us first talk about what a regular tobacco cigarette is.
I will try to keep it simple.
A regular cigarette is made up of tobacco and several other substances wrapped up into a roll. When the tobacco is lit up, it burns to produce a mixture of gases that contain lots of toxic substances, which then turn into smoke that is inhaled through a filter. The purpose of the filter is mainly to improve the taste of that vapour, so do not be misled into thinking that this filter actually filters out any toxic substances.
And what does this smoke contain? Not only nicotine, but many other horrible substances. And add to that some more toxic and carcinogenic content. Simply addiction and self-destruction, that is what these cigarettes are.

What are electronic cigarettes?

Here too, let’s keep it simple.
I’m not going to go into all the different features found in the different vaping devices that exist. They all work based on the same concept – rather than lighting or burning tobacco as happens in a regular cigarette, the electronic cigarette contains an electric device that turn liquid into vapour (read more below about what this liquid contains).
The electronic cigarette contains a device that heats up on batteries, and this warms the liquid, causes it to evaporate and turn into an aerosol that is inhaled into the lungs.
Since there is no burning process here, smoke is not formed, and the familiar smell of tobacco is not released (as it would be in a regular cigarette).

What are the devices used to heat up tobacco?

At first glance these devices may seem like just another type of electronic cigarette. But they are a little different.
These devices used to heat up tobacco utilize tobacco for that purpose. Technically, however, the device heats it up to a level below its burning point. The manufacturer claims that this allows for the substances that are released to be less toxic than the ones released with the regular burning of tobacco. These devices were approved by the FDA in the United States in 2019 but the scientific evidence with regards to their risks and benefits are limited.

What does the vaping liquid in electronic cigarettes contain?

Okay, so the regular cigarette contains tobacco and a few other substances.
The electronic cigarette contains a combination of propylene glycol, glycerin (a substance that becomes volatile when it comes in contact with the cigarette’s heating coil and forms the aerosol), nicotine (this may be present in varying concentrations or not present at all, as you will see below, and sometimes there may be nicotinic salt and benzoic acid, to boost the effect) and flavorings, a general name given to a bunch of substances that may sound completely benign but really, who knows?
Some of the products contain additional substances such as heavy metals and other ingredients that have complicated chemical names. And some products also contain cannabis or cannabis oil (read more about the implications of this below).
Varying aerosol volumes and smoking sensations can be produced by changing the ratios of the propylene glycol, glycerine and other ingredients found in the product.

Does the electronic cigarette have detrimental health effects?

This is the million dollar question. Let me just dive right into the answer. The electronic cigarette is a relatively new product (was introduced into the market at the beginning of the 2000s), and so its risks are not yet fully understood. It will be a while before all the data is collected and long-term studies are conducted so we can fully understand the extent of its harm, at a level comparable to what we now know about the risks of regular cigarette smoking. But the short and medium-term risks are starting to show up. The types of injury these aerosols may cause to our lungs can be divided in several different ways.

Electronic cigarette or vaping product use-associated lung injury (EVALI)

In 2019, the Centers for Disease Control and Prevention (the CDC) in the United States reported cases of lung injury after the use of electronic cigarettes, mainly in young men with underlying medical conditions such as asthma, obesity etc. (read more about obesity in children here).
These patients usually complain of shortness of breath, cough, sometimes bloody cough, chest pain, fever at times, shivering and weakness. In addition, there have associations with gastrointestinal symptoms such as abdominal pain, nausea, vomiting and diarrhea.
Some of the patients present with low blood oxygen levels. A rather large number need intensive care and about a third of those in intensive care eventually require mechanical ventilation. About 7% of them require Extracorporeal membrane oxygenation (ECMO, a machine that replaces the heart-lung activity temporarily) treatment. Some of them, unfortunately, do not make it.
Despite the short period of time that has elapsed since the discovery of this syndrome, we already know that a percentage of those people who have had it continue to suffer from long-term chronic illnesses following resolution of the acute symptoms. The precise mechanism of lung injury is unknown but several hypotheses have been proposed following observation of the microscopic injury caused to the lung tissue.

What are the risk factors for development of EVALI?

Several risk factors have been suggested:
 Use of cannabis – there is evidence that there was cannabis in the liquid that most of the patients who have developed the disease were smoking or that they had been simultaneously smoking cannabis in addition to the use of electronic cigarette. Note that even if the smoker may think he/she are not consuming cannabis, they must remember that the liquid they are purchasing may still contain cannabis or cannabis oil.
 Vitamin E acetate – this is an artificial additive that is found in some of the liquids that contain cannabis and it seems like it may play a strong role in the development of lung injury.
 Other substances – as this is a new disease that is still being studied on animal models, and as there have been other substances that have been suggested to play a role in the injury such as oil products and even nicotine, it is still possible that the combination of several substances together forms toxic substances that have not yet been discovered.
It is important to note though, that in the series that have been published so far, a large percentage of the patients reported use of liquid that they had purchased through random people and from unofficial places. Some of them used additives to boost the effect of the liquid. Some had placed the substances right onto the heating device. What I’m trying to say is that if someone wants to experiment with this device, they should really try to look into the ingredients that have been added to the liquid and where they came from. But really, is it even possible to track down all the possible content and its potential harm?

Chronic lung injury and risk of cancer associated with electronic cigarettes

The truth is that we do not have enough information to be able to tell. It may well be that the amount of toxic inhalants is less than or different to what is normally released and inhaled in a regular cigarette, but there is no real way for us to determine this. And we do not have a way to find out whether it causes any less harm. We are also unfamiliar with the long term implications of inhaling propylene glycol and glycerin, especially not the type that has undergone heating and vaporization. We are familiar with the adverse carcinogenic products produced by these substances. So, all you people who are inhaling these liquids into your lungs are – you are in fact, participating in a trial. Sometimes these trials work, other times they don’t.

Signs and symptoms of irritation of the respiratory tract associated with electronic cigarettes

There are case series that have described bronchitis and asthma-like symptoms associated with the use of electronic cigarettes. It is obviously very unpleasant to walk around all day with a productive cough, but beyond that – what are the long term implications of such inflammatory processes in the lungs? Nobody really knows.

Exposure to nicotine

Since the liquid contains nicotine, it is obvious that the use of electronic cigarettes entails exposure to nicotine. Is there a big difference between this exposure and the one from regular cigarettes? Yes, just like there is a difference between someone who smokes one cigarette per day and someone who smokes a whole pack a day. It depends on the concentration of nicotine found in the liquid, the vaping device, the frequency of use, the amount and manner of inhalation etc.

Does the use of nicotine alone without smoking increase the risk of cardiovascular diseases?

Based on the clinical trials that have been conducted on adults who were consuming nicotinic substitutes, it seems like the use of nicotine alone does not increase the risk of cardiovascular disease.
There is scientific evidence with regards to the effect of nicotine exposure on blood pressure and other cardiovascular measurements but this effect is unclear.
But please do not be mistaken, we do know that cigarette smoking certainly increases the risk for cardiovascular disease because of nicotine and many other substances that play a role in this. Similarly, electronic cigarettes contain many other ingredients that may have an effect that we are still unfamiliar with.

Can exposure to nicotine in the vaping liquid in the electronic cigarettes lead to the smoking of regular cigarettes and addiction?

It seems like it does. Even though the evidence to this is conflicted. A large study that was published in JAMA Pediatrics in 2017 (PMID:28654986) attempted to review the association between initial use of electronic cigarettes and subsequent cigarette smoking among 17,389 adolescents and young adults aged 14-30 years. In this study 30.4% of the those who had initially used electronic cigarettes subsequently started cigarette smoking as opposed to 7.9% of those who had never used electronic cigarettes prior to smoking regular cigarettes. Following standardization for several different confounding factors, a person who had used an electronic cigarette in the past had 3.62 times the risk of becoming a cigarette smoker compared to someone who hadn’t (that is almost 4-fold the risk!).
I know that studies have lots and lots of limitations, and different studies may show opposite results. And there are even research studies out there about the efficacy of electronic cigarettes in reducing smoking or even causing people to stop smoking. So, what is really going on here?
I’ll tell you what I do want you to take home from all of this.
First of all, it is a bad habit. This habit of sitting down and smoking and enjoying it in the company of other adolescents may lead some to smoking regular cigarettes or even to them using other substances. And being in such an atmosphere may bring about other behaviours, as well.
Secondly, it turns the whole topic of smoking into something positive and even pleasant. Even if we can’t prove it based on research, it is enough to watch few of the adolescents in your locality move on from electronic cigarettes to smoking regular cigarettes to feel the disappointment.
Thirdly, does the use of electronic cigarettes cause an addiction to nicotine and the desire to consume more of it? Regardless of whether it is through electronic cigarettes or regular cigarettes. Just think about it.

Negative effects caused by the vaping device and poisoning from the vaping liquid

This may not sound as important, but it still happens. These devices are electronic, and work on batteries, and just like chargers and scooters they can sometimes explode. If this happens in someone’s face or in their pocket, it could cause serious injury. Also, there have been reports of cases where kids were poisoned after coming in contact with or drinking the vaping liquid.

Is the use of electronic cigarettes that do not contain nicotine harmful?

Scroll up to the paragraphs in the beginning of this post. One could suppose that simply inhaling different flavors isn’t that harmful to us. But let me remind you that these vaping liquids contain several substances other than nicotine, some of which are known to be harmful and others with unknown effect. And also – this brings me back to bad habits and how they can affect us and what they could lead to.
We also do not know much about the flavoring ingredients that are used. There is a lot of scientific evidence about the injury that can be caused to cells as a result of products released from vaping liquids containing cinnamon flavorings (the substance is called diacetyl for those of you who want to read more about it). Cherry flavorings, for example, contain benzaldehyde, which is known to cause respiratory irritation. I don’t know what all the other fruit flavorings contain but I do know that you cannot completely disregard their presence in the liquid and we must give their potential harmful effects some thought, as well.

What is happening around the world?

According to data published in the Centers for Disease Control and Prevention (CDC) and the FDA in November 2022, more than 1 in 10 middle and high school students (3.08 million!) had used some sort of a tobacco product during the past 30 days. Approximately 3.7% of all students surveyed reported currently smoking combustible tobacco products and 3.5% reported current use of multiple tobacco products. The most commonly used types of devices are E-cigarettes (9.4%), cigars (1.9%), cigarettes (1.6%).
These numbers are not good, my friends.

To conclude, speaking as someone who has, by now, earned the credit that I only want what is best for your children – let me tell you what I think.
I know that regular cigarettes are terrible, and we must keep ourselves and our children away from them. Electronic cigarettes are a new invention, and there is a whole market behind them making millions by taking advantage of the idea that regular cigarettes are harmful, and that their use is becoming more restricted, and the electronic cigarettes substitute is ‘healthier and more magical’.
We are still unaware of all of their adverse effects, but we do know about some of them, and I really do not believe that they are a benign or ‘naïve’ product in any sort of way. I certainly do not see anything healthy about them and I see no reason for adolescents to be using them.
How will the authorities regulate their use? I do not know. These products are still available for purchase in stores and on the internet, to date. However, I suggest you use the money it would cost you to purchase these products and ‘waste’ it on better habits, habits that have been proven to be beneficial for you and your health.
Take care of yourselves and your children, my friends.