In recent weeks, vaping and the use of e-cigarettes have been at the center of media attention. With the long-term effects of vaping unknown, and a rise in e-cigarette and vaping product use associated lung injury (EVALI), the safety of vaping is under investigation. As of October 31, 2019, the Centers for Disease Control and Prevention (CDC) confirmed that there have been 34 vaping-related deaths in 24 states. To date, there have been 1,604 cases of lung injury reported in 49 states and one territory.1
A statement from the US Surgeon General said he is “emphasizing the importance of protecting our children from a lifetime of nicotine addiction and associated health risks by immediately addressing the epidemic of youth e-cigarette use. The recent surge in e-cigarette use among youth, which has been fueled by new types of e-cigarettes that have recently entered the market, is cause for great concern.”2 This gives way to an important question: how much do we really know about this new “alternative” to smoking?
History of vaping
In 2003, Hon Lik of Beijing created the first commercially produced e-cigarette. Four years later, e-cigarettes were introduced in the United States.3 Between 2011 and 2015, the number of teens using e-cigarettes increased an astounding 900%, making e-cigarettes the most commonly used nicotine product for middle- and high school-aged children.4,5 In September 2019, the Drug Enforcement Administration (DEA) reported that approximately “37% of 12th graders admitted to vaping within the last year, an increase from 27.8% in 2017.”6 This increase in nicotine use has created a massive setback in the US campaign efforts to reduce the use of tobacco in young populations.
How does vaping work?
Vaping is referred to by a variety of names—vapes, electronic nicotine delivery systems (ENDS), hookah pens, mods, vape pens, and tank systems. For the purpose of this article, we will refer to these devices as e-cigarettes. E-cigarettes are battery-operated devices with a heating element that heats up an e-liquid solution that is then converted into a vapor that is inhaled by the user. The vapor created is a chemical vapor considered to be “smokeless.” In addition, e-cigarettes can be a vehicle to deliver marijuana and other addictive and illegal drugs.
What does an e-cigarette look like?
While e-cigarettes come in a wide variety of shapes and sizes, the general function is the same. Some e-cigarettes look like USB flash drives, while others are much bulkier. Some of these devices can be particularly deceiving because they are small and fit easily into the palm of your hand and are difficult to detect. All e-cigarettes have a battery, an atomizer (used to turn e-liquid into a vapor), a cartridge that contains the e-liquid, and a mouthpiece that is used to inhale the aerosols (figure 1).
What are the ingredients?
E-liquids have fewer ingredients than traditional cigarettes. It is because of this that vaping is perceived as a “healthier” and safe alternative to cigarettes, despite the fact that e-liquids are still an addictive product. The vapor that is exhaled by those using e-cigarettes is a harmful combination of aerosols. The primary ingredient in almost all e-liquid is nicotine, but there are other components that users may not be aware of. E-liquid solution typically contains propylene glycol, vegetable glycerin and flavorings, formaldehyde, benzene, and other volatile organic compounds.
According to a survey conducted in 2013-2014, 81% of current e-cigarette users stated that the biggest appeal to e-cigarettes is the flavors.7 In addition to the ingredients mentioned, e-cigarette users may also be using an e-liquid containing tetrahydrocannabinol or cannabidiol oils. While the names of these chemicals may not mean much to the average person, it is important that health-care providers and the general population have a good understanding of what these chemicals are used for and where they are found.
Propylene glycol—This is used for processing foods and is found in sweeteners, ice cream, and whipped cream. In e-cigarettes, this odorless and slightly sweet ingredient is used as a carrier for the nicotine.
Glycerin and other flavorings—This odorless and slightly sweet liquid is used as a humectant, solvent, and sweetener.
Nicotine—Each e-cigarette contains approximately 0.3% to 1.8% nicotine. Depending on the size of the e-cigarette cartridge, it is the equivalent of smoking two to three packs of cigarettes.8
Benzene—This is an industrial chemical used in gasoline production, and is also used to make plastic, resin, and synthetic fibers, among other industrial uses.9
Formaldehyde—This is a colorless and odorless chemical that is used in building materials and is an ingredient in many household items. The level of formaldehyde released increases as the levels of heat rise in an e-cigarette.10
Volatile organic compounds—These compounds are known to be toxic and carcinogenic. These can be found in cigarettes, adhesives, craft supplies, and various other products.11
The e-vapor that is released into the environment poses risks not only to the user but to nonusers, exposing them to secondhand vapor (figure 2). E-vapor contains the harmful chemicals noted above and can cause systemic health issues ranging from heart and lung disease to cancer.
Statistics
- While the statistics are staggering and continue to roll in, this is what is currently known about e-cigarettes and their use.
- In 2018, 3.62 million middle and high school youth were using e-cigarettes. This is the most commonly used tobacco product in the US.7
- In 2017 and 2018, there was a 48% increase in e-cigarette use in middle school youth and 78% increase for high school teens.7,12
- Since October 1, 2019, 80% of patients with lung injury cases associated with e-cigarettes were under the age of 35.1
- E-liquids come in a variety of flavors, such as mango, bubblegum, and cotton candy, which appeal to young people.
- The FDA or CDC has not been able to link EVALI to one specific product or brand.
Health implications
The biggest hurdle with e-cigarettes is that the long-term effects are not known. In recent months we have become more aware of the effects of e-cigarettes on the lungs, but the exact cause or culprit has not been validated. More longitudinal research is needed to identify the systemic health risks of e-cigarettes. Research is also needed to understand how to identify and treat those with health problems due to vaping, and the long-term prognosis of vaping.
A large number of government agencies are monitoring this epidemic very closely, from the Federal Drug Administration (FDA), CDC, and the US Surgeon General. In addition, organizations such as the American Heart Association, American Academy of Pediatrics, American Lung Association, and the American Cancer Society are monitoring vaping trends and research. These organizations are recommending that teens and young adults abstain from vaping and be aware of the health risks associated with this behavior.
As health-care professionals, we must identify patients who use e-cigarettes. Not all patient health histories specifically ask about vaping, and it is common that those who vape do not consider it smoking. Patients must be directly asked whether they vape. We need to know how long they have been using e-cigarettes, what products they use with it, and how often they use it. Because we don’t understand who’s at the highest risk of developing EVALI, all vape users should be aware of the range of symptoms of EVALI and seek treatment immediately should symptoms appear. These include chest pain and shortness of breath, cough, fatigue, vomiting, diarrhea, and fever.
Warnings for users and families
Vaping is not considered an alternative or safe option to smoking, nor should it be used as a method to help quit smoking. At this time, the FDA has not approved e-cigarettes as an effective method for smoking cessation. In addition to nicotine, e-cigarettes and cigarettes contain many of the same chemicals. One of the differences between vaping and traditional cigarette use is that some of the known chronic illnesses and diseases associated with smoking appear after long-term use of the products. The effects of e-cigarettes can be detected after a much shorter time. Users can sometimes see the adverse effects of vaping within the first year.
According to the National Center for Health Research, it was not initially expected that severe lung damage could be caused by e-cigarettes in a short period of time.3 Traditional cigarette smoke is known to cause damage to the lungs and heart, and it can cause a wide variety of cancers. Due to the fact that chemicals used in cigarettes are also in e-liquid, it is safe to assume that users are not reducing their risks of developing these chronic diseases by using e-cigarettes.
Vaping is especially dangerous and damaging to youth because chemicals in the e-liquid interfere with brain development. This disruption in brain development from nicotine interferes with memory and attention processing.14 Nicotine can also cause changes in mood and self-control. In 2018 the American Chemical Society demonstrated changes in DNA after 15 minutes of vaping. Participants’ saliva displayed significantly high amounts of the dangerous chemicals formaldehyde and acrolein, which are known to cause damage to DNA.13,15 Evidence such as this is what makes this epidemic very alarming. The use of e-cigarettes increases the likelihood of smoking traditional cigarettes or using other forms of tobacco. Even more disturbing is that young generations do not view vaping as harmful or addictive.
Looking toward the future
The FDA currently has not outlawed or restricted the use of e-cigarettes. However, individual states have the ability to pass laws pertaining to e-cigarettes. Specific laws for each state can be found online on the Public Health Law Center website at publichealthlawcenter.org/resources/us-e-cigarette-regulations-50-state-review.13 The campaign used to decrease tobacco use in teens and young adults was successful; therefore, the same campaign initiatives may apply to e-cigarettes.
With the alarming increase in e-cigarette use during the last 12 years, there should be a sense of urgency to reduce the number of e-cigarette users. Ultimately, the public needs to be educated about the dangers and risks of using e-cigarettes. This education can come from many sources—parents, schools, health-care providers, advertising, and government agencies. E-cigarettes and the legalization of marijuana will only complicate the statistics and require additional research. There is an urgent need for substantial research on the effects of vaping, especially in the youth and young adult populations. The time to act is now!
References
1. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Centers for Disease Control and Prevention website. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. Updated November 14, 2019.
2. Surgeon General’s advisory of e-cigarette use among youth. Know the Risks website. https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf.
3. A Historical Timeline of Electronic Cigarettes. Consumer Advocates for Smoke Free Alternatives Association website. http://www.casaa.org/historical-timeline-of-electronic-cigarettes. Accessed October 19, 2019.
4. E-cigarette use among youth and young adults: A report of the Surgeon General.Know the Risks website. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf. Published 2016.
5. FDA proposes regulations as teen e-cigarette use skyrockets 78% in 1 year. American Cancer Society website. https://www.cancer.org/latest-news/fda-proposes-regulations-as-teen-e-cigarette-uses-skyrockets-78-percent-in-1-year.html. Published November 21, 2018. Accessed September 20, 2019.
6. Teens and vaping.Get smart about drugs website. https://www.getsmartaboutdrugs.gov/content/teens-and-vaping. Published October 11, 2019. Accessed September 20, 2019.
7. Cullen KA, Ambrose BK,Gentzke AS,Apelberg BJ, Jamal A, King BA. Notes from the field: Increase in use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011-2018.MMWR Morbid Mortal Wkly Rep.2018;67(45):1276-1277.
8. Froum S,Neymark A. Vaping and oral health: It’s worse than you think. Perioimplant advisory website. www.perioimplantadvisory.com/clinical-tips/article/16412201/vaping-and-oral-health-its-worse-than-you-think.Perio-Implant Advisory. Updated January 10, 2019. Accessed September 5, 2019.
9. Benzene. Wisconsin Department of Health Services website. https://www.dhs.wisconsin.gov/chemical/benzene.htm. Revised November 20, 2018.
10. Formaldehyde. Wisconsin Department of Health Services website. https://www.dhs.wisconsin.gov/chemical/formaldehyde.htm. Revised October 1, 2019.
11. Volatile Organic Compounds (VOCs).Tox Town website. https://toxtown.nlm.nih.gov/chemicals-and-contaminants/volatile-organic-compounds-vocs. Published May 31, 2017.
12. 2018 NYTS data: A startling rise in youth e-cigarette use.FDA website. https://www.fda.gov/tobacco-products/youth-and-tobacco/2018-nyts-data-startling-rise-youth-e-cigarette-use. Updated February 6, 2019.
13. Gottschalk L, Fraga JA, Hirschfield J, Zuckerman D. Is vaping safer than smoking cigarettes? National Center for Health Research website. http://www.center4research.org/vaping-safer-smoking-cigarettes-2. Accessed September 5, 2019.
14. Raven K. Teen vaping linked to more health risks. Yale Medicine website. https://www.yalemedicine.org/stories/teen-vaping. Published November 8, 2019.
15. Lee HW, Park SH, Weng MW, et al. E-cigarette smoke damages DNA and reduces repair activity in mouse lung, heart, and bladder as well as in human lung and bladder cells. Proc Natl Acad Sci USA. 2018;115(7):E1560-E1569.
MELISSA VAN WITZENBURG, MS, RDH, has been practicing dental hygiene for 17 years. She continues to pursue her passion by assisting in the creation of an oral health initiative to educate the aging population about oral health and systemic links. Van Witzenburg also works clinically in a periodontal office in the Chicagoland area. Email her at [email protected].
