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

by Joseph K. Clark

Though more than a billion people worldwide still smoke cigarettes, folks looking to kick the habit have many modern assistive techniques and technologies at their disposal. However, among the talk therapies and transdermal nicotine patches, no smoking cessation aid has perhaps impacted pop and mainstream culture more than e-cigarettes. Excerpted from Viral BS: Medical Myths and Why We Fall For Them by Dr. Seema Yasmin, published by Johns Hopkins University Press. Dr. Seema Yasmin examines controversies surrounding tobacco replacement technology and other “common” medical knowledge in Viral BS: Medical Myths and Why We Fall for Them. In the excerpt below, Yasmin recalls the months of 2019 when vaping briefly took a turn for the deadly. Copyright © 2021. Used by permission. All rights reserved.

In 2019, young people, primarily young men in Illinois and Wisconsin, began to fall sick with 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 lung disease in Illinois. Another died from the same condition in Oregon. In October, a boy was killed in New York, becoming the first teenager to die from the mysterious disease.

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


Investigators seeking clues found that ingredients in the liquids 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 quit smoking. At the same time, 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 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 2019, as the outbreak of EVALI continued to grow, the FDA conducted its investigation and found vitamin E acetate in the cannabis vaping products of nearly every person sick with EVALI in New York. The FDA said it was being added as a thickening agent and possibly increased THC levels, the main psychogenic compound in cannabis. 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.

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 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 systems or open tanks and closed systems or closed tanks. The vaporized liquid can be manually refilled in an available tank, 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 Hon Lik, a Chinese pharmacist, and smoker, created the first commercially successful e-cigarette. 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 the market research group Euromonitor—the use of e-cigarettes is rising dramatically.

According to Euromonitor, the number of e-cigarette smokers has increased fivefold in five years, going up from 7 million in 2011 to 35 million in 2016. 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. The United Kingdom, Japan, and the United States established 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 as American teenagers’ most popular tobacco products. According to the CDC, one in five 18- to 24-year-olds in the United States has used an e-cigarette.

Cigarettes contain thousands of compounds, at least seventy known carcinogens. They also contain carbon monoxide, arsenic, and other poisons. On the other hand, E-cigarettes have 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 to propylene glycol.

The relative novelty of e-cigarettes means a lack of long-term safety data. In studies, some e-cigarette vapor has been found to contain deficient levels of nitrosamines, which have been linked to cancer. Other studies have shown that the smoke contains toxic chemicals, including acetaldehyde and formaldehyde, and some flavorings, especially cinnamon, butter, and vanilla, contain free radicals, damaging DNA. 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 rate of people who had successfully quit smoking cigarettes in England. But there’s conflicting evidence about the effectiveness of e-cigarettes as a tool for smoking cessation.

In a 2018 study of more than 6,000 smokers, researchers at the University of Pennsylvania found e-cigarettes did not help cigarette smokers kick the habit. (Cash incentives were.) in the same report, Public Health England says 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 impact.

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 quit 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 the 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 smoke regular cigarettes. Scientists at the University of Hawaii found e-cigarettes promote 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 when first interviewed. A year later, students who had previously smoked e-cigarettes were nearly three times more likely to have tried a regular cigarette than 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 quit 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 has swayed the RCP and Public Health England. E-cigarettes have now outpaced nicotine gum and patches to become Britain’s most popular tool for smoking cessation.

The FDA has not licensed e-cigarettes as a tool for smoking cessation. The agency offers a warning about the risks posed by e-cigarettes. In 2009, the FDA analyzed the liquid contents of 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 the vaping fluid. ErectileThe medicines could dangerously lower blood pressure, the agency said. Dysfunction drugs Viagra and Cialis, which should be available only with a prescription, weres discovered inside e-cigarette liquids made by the Chinese e-cigarette maker HelloCig Electronic Technology. The med g to the US Fire Administration, more than two dozen people were injured by exploding e-cigarettes from 2009 to 2014. Doctors say those injured suffer flame burns, chemical burns, and blast injuries. Public There’s also a threat of damage when the battery inside an e-cigarette overheats. 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. Without national 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.

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