Is Vaping Bad For You? Is It Safe? Experts Weigh In
Vaping, the practice of inhaling vaporized liquid as a substitute for smoking, constitutes the latest chapter in the deeply interwoven history of America, tobacco and technology. But does it represent actual progress from the public health crisis caused by cigarettes, or is this new nicotine delivery system just a more-fashionable, yet similarly harmful drain on our health – both physical and financial? It’s already a multi-billion dollar market, after all.
Although vaping has not yet been put under quite the same microscope as cigarettes, the research done to date paints a fairly consistent picture of the habit’s effects. For starters, vaping appears to be a relatively benign alternative to smoking cigarettes, which are far more dangerous given the carcinogens they contain and the chemicals that are released through the combustion of plant matter. According to a 2014 study by a team of researchers from the UK Centre for Tobacco and Alcohol Studies, “Smokers who had used an e-cigarette in their most recent quit attempt were more likely to report abstinence than those who used [a nicotine replacement therapy] bought over-the-counter.”
That, however, does not mean the practice is entirely safe. Although vaping lacks the cancer-causing elements of cigarette smoking, new data show that it’s actually more harmful to one’s immune system, inhibiting the function of 358 genes associated infection-fighting, compared to just 53 for smoking. What’s more, a 2016 study by researchers at the University of Southern California showed that 13.7% of high-school students either smoked or vaped in 2014 compared to just 9.0% who smoked in 2014, indicating that vaping is a more attractive gateway to nicotine than cigarettes.
But with all of that being said, this debate is far from settled. So in the interest of advancing the discussion, we invited a panel of public health and addiction experts to weigh in. We asked them whether vaping is unhealthy or safe (at least compared to cigarettes), and you can check out their responses below. All in all, twelve experts say vaping is safer than smoking cigarettes, six believe vaping is bad and three contend that there’s just not enough reliable data yet.
Vaping Is Safer Than Smoking
- “The vapor is not completely safe compared to having no vapor – it has propylene glycol and small amounts of some other toxic chemicals, mostly for flavoring. However, studies show very small amounts of harmful chemicals in the vapor compared to the very large harmful properties of burned tobacco. E-cigarette use has been shown to reduce exhaled carbon monoxide and self-reported respiratory symptoms over time. Therefore, while non-smokers should not have to be exposed to vapor, for smokers to switch to e-cigarettes would greatly reduce their exposure to toxic chemicals and particles.”
- Damaris J. Rohsenow, Ph.D. // Associate Director of the Center for Alcohol and Addiction Studies, Brown University School of Public Health
- "In discussing the safety of e-cigarettes, it is important to recognize that nothing is absolutely safe; for example, prescription medicines lead to over 30,000 deaths each year in the U.S. Even over-the-counter medicines like aspirin and related pain relievers cause thousands of deaths per year. Therefore, a more relevant question is whether e-cigarettes are reasonably safe for current smokers to use in place of conventional combustible cigarettes. Based on available evidence, e-cigarettes are almost certainly far less harmful than combustible cigarettes. The U.S. Surgeon General and other experts have linked the vast majority of smoking-related disease to the combustion products of smoke, not to the nicotine per se."
- Jed E. Rose, Ph.D. // Director of the Center for Smoking Cessation, Duke University Medical Center
- “Choosing between ‘safe’ or ‘unsafe’ labels for e-cigarettes misses the point. No consumer product is absolutely safe. Those terms are especially meaningless for 39 million U.S. smokers who know they should quit but have not. Smokers have been seriously misinformed about the relative safety of vapor products; only one-quarter of them know vaping is less harmful than smoking. Tragically, misinformation keeps people smoking and keeps smokers dying.”
- Brad Rodu, D.D.S. // Endowed Chair for Tobacco Harm Reduction Research at the University of Louisville’s James Graham Brown Cancer Center & Senior Fellow at The Heartland Institute
- “Compared to cigarettes, there should be no debate that vaping is much safer. However, compared to breathing the air, vaping is probably riskier, although one might be able to debate this depending upon where you live these days. The concept of separating the nicotine from cigarette smoke is an old idea, but a good one, since smokers smoke for the nicotine but end up dying as a result of their repeated exposure to the many dangerous chemicals in cigarette smoke.”
- K. Michael Cummings, Ph.D. // Co-Director of the Hollings Cancer Center’s Tobacco Research Program, Medical University of South Carolina
Studies have also shown that e-cigarettes can help people quit smoking, and that they are more effective in reducing smoking than conventional nicotine replacement therapy, e.g., the nicotine skin patch. By replacing the habit of smoking and delivering the nicotine to the user more rapidly, it is not surprising that e-cigarettes can be efficacious for smoking reduction and cessation. Still, it would be ideal for smokers to quit smoking entirely using extremely safe and well-proven agents such a nicotine replacement therapies, varenicline or bupropion (and/or behavioral treatments). But if these do not work for a given smoker, and if the choice is between switching to e-cigarettes, or continuing to expose oneself to the enormous and known risk of continued smoking -- which kills 2 out of 3 long-time users -- then it is entirely reasonable to switch to e-cigarettes.
Author disclosure: I have devoted my career over the past 35 years to the development of more effective smoking cessation treatments. I have contributed to the development of the nicotine skin patch, provided data supporting the rationale underlying the development of varenicline, and developed personalized, adaptive smoking cessation treatment algorithms. The worldwide annual death toll from smoking and the limited long-term success rates of abstinence-oriented cessation treatments has convinced me that harm reduction has an important role in reducing the adverse public health impact of smoking. In recent years, I have also contributed to the invention of novel approaches to nicotine inhalation for tobacco harm reduction or cessation. Along with the U.S. Food and Drug Administration and proponents of the Family Smoking Reduction and Tobacco Control Act, I have accepted that the tobacco industry has a valid and major role in developing reduced risk tobacco products. I have accepted research funding from the tobacco industry, under conditions that provide transparency and oversight to ensure research integrity, and currently serve as a paid consultant to Philip Morris International, specifically to support development of reduced risk products. I am listed as an inventor on a nicotine inhalation technology sold to that company, but have no financial interest in the future sale of products.
Cigarette use is known to be very harmful, and many people have been unable to stop smoking. Most of the harm does not come from nicotine but from the carbon monoxide and other aspects of the tobacco leaf burning (particulates and tar, for example). Nicotine itself is not a cause of cancer. A recent review concluded that most of the chemicals in cigarettes that cause diseases are absent in e-cigarettes. Therefore, there are many scientists who think that if smokers who are addicted to cigarettes were to switch to e-cigarettes, they would reduce their exposure to harmful chemicals and reduce their risk of cancer, lung and heart disease.
Great Britain (Public Health England) recently concluded that e-cigarettes can help smokers who couldn’t quit smoking to reduce or quit their use of cigarettes. Therefore, they adopted one form of e-cigarette as a form of nicotine replacement that their health care providers can prescribe.
The vapor is not completely safe compared to having no vapor – it has propylene glycol and small amounts of some other toxic chemicals, mostly for flavoring. However, studies show very small amounts of harmful chemicals in the vapor compared to the very large harmful properties of burned tobacco. E-cigarette use has been shown to reduce exhaled carbon monoxide and self-reported respiratory symptoms over time. Therefore, while non-smokers should not have to be exposed to vapor, for smokers to switch to e-cigarettes would greatly reduce their exposure to toxic chemicals and particles.
For those who don’t smoke, it makes no sense to take up vaping. Even if the risks of vaping are minimal, there is no real benefit to be gained for non-smokers. However, this is not the case for smokers who would certainly be better off trading in their Marlboros for a vaping product.
Many of the hazardous chemicals in cigarette smoke are not detectable in vaping products or, if found at all, are present in concentrations that are much lower than in cigarette smoke. While nicotine is the main addictive chemical in tobacco and vaping products, we now know that nicotine by itself has relatively minor health effects except for in pregnancy and perhaps in those with pre-existing cardiac disease. Nicotine is not a carcinogen and does not cause respiratory disease. Studies of long-term users of oral tobacco products such as snus (moist, oral tobacco used in Sweden) and nicotine medications (i.e., gum, patches, and lozenges) have found that long-term use of nicotine without the smoke is much safer than smoking.
Unfortunately, many smokers are misinformed about the relative health risks of cigarettes compared to other forms of nicotine delivery. In response to this problem, the Royal College of Physicians recently issued a statement indicating that the long-term health risks from vaping are unlikely to exceed 5% of the harm from smoking cigarettes. In other words, cigarette smokers would certainly be much better off vaping compared to smoking cigarettes. The problem is many people who vape also keep smoking cigarettes negating any real health benefit. On the other hand, an increasing number of smokers have turned to vaping as a means to wean themselves off of cigarettes which is a good thing. In fact, studies suggest that vaping may be as effective for smoking cessation as nicotine medications. Importantly, vaping products my represent a more attractive alternative to cigarettes for many smokers due to their greater accessibility and lower relative cost compared to cigarettes.
Unfortunately, in their zeal to protect nonsmokers, some governments and health organizations have taken a risk-averse view on nicotine and vaping products without seriously considering their potential health benefits. Most smokers want to quit and are looking for viable options to help them overcome their nicotine addiction. In the absence of giving smokers good alternatives, most will keep smoking. With appropriate and measured regulations to ensure the safety of vaping products, making these products more widely available has the potential to save the lives of millions of smokers.
Smoking-related diseases are pathophysiologically attributed to oxidative stress, activation of inflammatory pathways, and direct toxic effect of thousands of chemicals and carcinogens present in tobacco smoke. These chemicals are emitted mostly during the combustion process, which is absent in ECs. Under normal conditions of use, vapor toxicology is far less problematic than that of conventional cigarettes, ECs being at least 96% less harmful compared with combustible cigarettes. Thus it is not surprising that direct toxicological evaluation in the blood, urine and exhaled breath of ECs users shows that substitution of cigarettes with ECs exposes them to only a fraction of toxicants compared to combustible cigarettes. Last but not least, product innovation will drive any residual risks from EC use to as low as possible.
Switching to less harmful forms of nicotine delivery may have long-term beneficial health effects. There is now emerging evidence for harm reversal to EC users, particularly for those with preexisting disease (e.g. asthma, chronic obstructive pulmonary disease, arterial hypertension, schizophrenia). Of particular relevance, improved lung function, respiratory symptoms, quality of life, subjective/objective outcomes have been documented in asthmatic and COPD smokers who switched to vaping. Exposure to e-vapour in these vulnerable populations did not trigger acute respiratory symptoms.
While stopping smoking results in considerable health improvements, it is accompanied by weight gain in four out of five quitters. The problem of post-cessation weight gain can have important health consequences considering that smoking and obesity are both risk factors for cardiovascular disease, type II diabetes, and some cancers. Thus, it is important to emphasize that smokers who quit smoking by switching to ECs have been shown to limit their post-cessation weight gain.
Researcher Michael Russell said in a study published in 1976, “People smoke for nicotine but they die from the tar.” No study to date that I am aware of demonstrates any level of tar contained in e-cigarettes. In 2014, Mitch Zeller of FDA’s Center for Tobacco Products testified before the United States Senate, “If we could get all of those people [who smoke] to completely switch all of their cigarettes to noncombustible cigarettes, it would be good for public health”. In the UK, both Public Health England and the Royal College of Physicians have reviewed the available scientific literature and found vaping to be at least 95% less harmful than smoking.
In the United States, however, the public health focus has been very different. Rather than embracing technology with potential to all but eradicate combustible tobacco use, some take the bizarre approach of encouraging smokers not to quit. Medical doctors with years of training somehow believe “e-cigarettes are just as bad”. The complete contradiction of both common sense and the growing body scientific evidence is nothing short of staggering.
Regrettably, much of the pseudo-science surrounding e-cigarettes is produced right here in the United States. A study published in the New England Journal of Medicine was widely criticized by experts as being misleading, and yet reporting to the public warned of the dangers of vaping, rather than the confirmation provided that e-cigarettes produce near-zero levels of formaldehyde when used as intended.
While long term study of vaping is without question reasonable and needed, the body of short term data we do have strongly supports the notion that vapor products eliminate nearly all of the harm from smoking. The evidence is clear that e-cigarette aerosol contains either significantly less or none of the toxins found in cigarette smoke with few exceptions. “The dose makes the poison”, the most basic tenet of toxicology, seems to have been put on the back burner.
By any reasonable standard, vaping must be viewed under the lens of harm reduction.
The available body of evidence we have today unequivocally indicates that vaping is safer than smoking.
According to the Centers for Disease Control and Prevention (CDC), smoking kills 480,000 Americans every year. Most smokers, however, don’t know they can reduce harm and save lives by easily transitioning to smoke-free products.
Smoke efficiently delivers nicotine, which is addictive but doesn’t cause serious harm. Smoke also delivers thousands of toxic chemicals that lead to cancer, heart attack, stroke, and deadly lung disease. For many smokers, complete abstinence from nicotine and tobacco is a pipedream. But switching to vastly safer, non-combustible tobacco products such as smokeless tobacco or e-cigarettes reduces harm nearly as effectively as quitting altogether.
This isn’t an empty claim. The British Royal College of Physicians, one of the oldest and most prestigious medical societies, has been encouraging smokers to switch to safer tobacco/nicotine products for nearly a decade. The Royal College acknowledged extensive research documenting the risks of smokeless tobacco amount to about 1 percent of those of smoking. Their message is clear and unequivocal: “[t]hat smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”
E-cigarettes are acceptable and effective as cigarette substitutes; they are used by 4.9 million current smokers and 2.5 million former smokers in the United States, despite their near-universal condemnation by American health authorities.
Why are e-cigarettes safer than cigarettes? Cigarette smoke contains thousands of toxins, while e-cigarette vapor contains only water, nicotine, propylene glycol or glycerin, and flavorings. Vapor may also contain contaminants, but they exist only at minuscule levels that are far lower than those found in cigarette smoke.
Earlier this year, the Royal College issued a report on e-cigarettes, in which it concluded, “[T]he hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco.”
Choosing between “safe” or “unsafe” labels for e-cigarettes misses the point. No consumer product is absolutely safe. Those terms are especially meaningless for 39 million U.S. smokers who know they should quit but have not. Smokers have been seriously misinformed about the relative safety of vapor products; only one-quarter of them know vaping is less harmful than smoking. Tragically, misinformation keeps people smoking and keeps smokers dying.
You can’t determine the acceptable risk of vaccines without contemplating the harm of contracting polio or yellow fever. In the same way, you can’t determine the acceptable risk of vaping without contemplating the harm associated with smoking. The CDC estimates that nearly 500,000 Americans die prematurely every year from smoking. Public health experts claim that if bold new interventions are not taken globally, over a billion lives will be cut short this century.
The oldest and most prestigious medical society in the world, the Royal College of Physicians, has concluded that the risks associated with vaping are “unlikely to exceed 5%” of those associated with smoked tobacco products, and “may well be substantially lower than this figure.” Because of this, the Royal College of Physicians advises that “in the interest of public health it is important to promote the use of e-cigarettes… as widely as possible as a substitute for smoking...”
Sadly, many people are prone to misunderstand the source of the risks associated with smoking. Let’s start with what it’s not. It’s not nicotine. Smokers are not developing heart disease and lung cancer from nicotine. While nicotine is a large part of why many smokers smoke, it’s the smoke itself that shortens and diminishes the quality of their lives. The damage is caused by lighting tobacco leaf on fire and breathing in the smoke hundreds of times per day, for many years.
Because vapor products do not rely on combustion, they are smoke-free and inherently far safer than smoking. The process of converting a liquid of relatively benign ingredients into a vapor, using far less heat, accounts for much of this difference. Nicotine -- in a range of highly diluted quantities -- is an optional ingredient in vaping liquids. But, when it is consumed in this fashion, it exists without the thousands of harmful chemicals found in cigarette smoke.
Consumer demand for vapor products has driven rapid innovation encompassing a wide variety of options. Millions of smokers are migrating to vaping and leaving their dangerous combustibles behind. Most importantly, they are doing so by choice and at no cost to taxpayers. Vapor products appeal to smokers because they are enjoyable and provide many of the pleasures of smoking, unlike FDA-approved smoking cessation products like patches.
It's unfortunate that people are playing word games with “safe,” rather than acknowledging the ways in which vaping is vastly safer. What’s most certainly not safe is perpetuating the falsehood that vaping is as dangerous or more dangerous than smoking as some irresponsibly continue to do. That misinformation causes long-term smokers to avoid trying much safer alternatives.
Another way to compare potential harmfulness is to examine biomarkers in the body fluids of people who use different products. A few recent studies have examined the concentration of toxicants in the urine of vapers and compared this with the concentration of toxicants in the urine of cigarette smokers. A study by Hecht and colleagues at University of Minnesota compared 28 e-cig users (various e-cig brands) who had not smoked for over 2 months with over 200 cigarette smokers, and examined the concentration of 6 markers of carcinogenic toxicants. The e-cig users had much lower levels of harmful toxicants in their urine than the smokers, and, in fact, their levels were no greater than never tobacco users. More recently, Goniewicz and colleagues at Roswell Park Cancer Institute measured 13 biomarkers of major carcinogens and toxicants in 20 cigarette smokers who then tried to completely switch to a single brand of e-cigs for 2 weeks. About half the participants completely switched and half continued to smoke at a much lower level while using the e-cigs. The levels of 13 harmful toxicants fell significantly within two weeks of switching from cigarettes to e-cigs.
These studies demonstrate that switching from cigarettes to e-cigs dramatically and quickly reduces exposure to numerous harmful toxicants, including known carcinogens. It is evidence like this that prompted an international panel of experts to estimate that use of e-cigs is likely to be around 95% less harmful than smoking cigarettes. E-cigs deliver nicotine and so can be addictive, although the evidence to date suggests that most e-cigs deliver less nicotine and are less addictive than cigarettes. Nicotine is not carcinogenic but it is not harmless, and, for example, is harmful to the unborn fetus if absorbed during pregnancy. So non-smokers should not start using e-cigs. But it is clear that switching from cigarettes to e-cigs is likely to reduce the risk of serious disease and premature death.
According to Public Health England, which conducted the most comprehensive review ever done on the topic, e-cigarettes are 95 percent less harmful than cigarettes.
England's Royal College of Physicians (RCP) recommended on April 28th that doctors "promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK."
Yet in the U.S., new FDA regulations will obliterate chances of smokers using e-cigarettes to quit. Meanwhile, leading public health groups including the American Heart Association, the American Lung Association and the American Cancer Society are actively lobbying against e-cigarettes and distorting the science about both the safety of e-cigarettes and how they can help cigarette smokers dramatically reduce their risk, as the RCP put it, by providing, "nicotine without the smoke."
Professor Michael Russell, whose research was the foundation for the 1988 U.S. Surgeon General's report on nicotine addiction, put it simply, "People smoke for nicotine but they die from the tar."
Yet anti-e-cigarette activists cavalierly claim that it will take decades to know whether e-cigarettes are less harmful than smoking. But we know a great deal about why cigarette smoking is so dangerous. It has a lot to do with the combustion of tobacco. We also know a tremendous amount about e-cigarettes, the liquid that goes into them, and what comes out of them when used. Are they "safe?" No. But not much is. Yet there's no question that they are dramatically less harmful than the most dangerous, widely used consumer product ever invented.
By sowing doubt about the lower risk of e-cigarettes, activists unwittingly give smokers the last thing they need: another excuse not to quit smoking.
Every time you see a former smoker using an e-cigarette, you are seeing the life-saving answer to the problem posed by Professor Russell's observation: How can we help smokers who can't or won't quit using nicotine?
That said, there are a number of important caveats to this statement.
First, all vaping products are not equal - the term “vaping” encompasses a wide range of products, used in many different forms, and with dizzyingly different ingredients.
Second, to say that vaping is safer than cigarette smoking – which is accurate, based on all data to date – does not mean that vaping is entirely safe. For example, long-term nicotine use is associated with increased risk of heart disease in some people, and children and adolescents and women who are pregnant should not be exposed to nicotine. Further, while data clearly suggest that short-term vaping is far safer than continuing to smoke cigarettes, no data are yet available regarding the health implications of long-term use of vaping products.
Third, just because vaping is safer than smoking cigarettes does not mean that it is a good thing to do. While many vapers report pleasant camaraderie while vaping with others, there is no health reason to vape except as a means of aiding an effort to quit smoking cigarettes.
Finally, concerns have also been raised regarding the potential for youth who vape to go on to use combusted cigarettes. There is a risk of “re-normalizing” cigarette smoking after years of progress in reducing cigarette use, and the emergence of “dual users”, i.e., cigarette smokers who do not use vaping products to quit cigarette use but, instead, use these products to continue to smoke and vaping only in places where cigarette smoking is not permitted.
Nevertheless, there is significant potential for vaping to contribute to the decline of combusted cigarette use. Data to date suggest that vaping as a means of quitting smoking may be about as effective in helping smokers quit as the six FDA-approved quit smoking medications (i.e., nicotine gum, patch, inhaler, and nasal spray, and bupropion and varenicline), although most U.S. medical organizations recommend using one or more of the FDA-approved medications before trying vaping as a means of quitting, since the FDA medications have been widely tested, proven safe when used as directed, and have known effectiveness profiles.
The bottom line is that vaping is certainly safer than cigarette smoking (two UK organizations – Public Health England and the Royal College of Physicians, have argued that vaping is as much as 95% safer than smoking cigarettes). Since cigarette smoking continues to exact a horrendous toll in the U.S. – the aforementioned half-millions deaths per year, many millions sickened every day, children exposed to secondhand smoke, and an annual cost to the economy of more than $300 billion in health care costs and lost productivity – any action, including vaping, which can help the nation’s 40+ million cigarette smokers to stop will be a great step forward for public health in the U.S.
“First, do no harm” is a bioethics of the medical profession, attributed to the Hippocratic Oath (although not appearing there). The origin is in another source, which enjoins physicians to “To do good, or to do no harm”. These similar sounding homilies engender radically different approaches to public health. First, do no harm enjoins us to disapprove any activity that might have a negative effect on the individual. Such indulgences include oral tobacco, marijuana, heroin, and, yes, vaping. To do good, or to do no harm enjoins us to improve the health or life quality of the individual. This is called a harm reduction agenda. Adherents to it genuflect in a very different church that that of their brethren. They do not impose what they think is best for their clients; instead they urge policies that will improve their longevity and quality of life. Thus, we hear that oral tobacco causes mouth cancer. This is true. What we do not hear is that it causes it at a much lower rate than do cigarettes, and does not carry the additional burden of lung cancer emphysema and other concomitants of smoking. The absolutist message here prevailed: If you had to choose between them you would be much better off with chew than with cigs; but most folks don’t know that.
The same message holds for vaping. For 30 years physicians and scientists have assured patients attempting to quit that NRT — Nicotine Replacement Therapy — was safe and non-addictive. This included nicotine inhalers, along with the patch and lozenges. I believe them. Addictive? A recent analysis of over 25000 individuals by scientists working at Pinney Associates estimated that the use of nicotine gum among adult never-smokers is 0 %. Among ex-smokers, that figure is 5 to 10%, and it was associated with a lower probability of cigarette use. Indeed, the problem is just that — vaping cannot replace tobacco, despite its healthier profile, because it is missing some critical ingredients. Those include monoamine oxidizers inhibitors, which ravage the brain in such a way that makes nicotine a perfect short-term fix. Of course, it also lacks all of the known carcinogens in tobacco.
So, is it safe? Merchandisers are adding stuff to e-cig oils that may be harmful if combusted and inhaled — just like the 600 additives approved for use in real cigarettes may be harmful if inhaled. We do not know if those are safe; we know that some can irritate the throat and lungs. So if you, a tobacco-virgin, are considering e-cigs because they are hip or because they stimulate thinking, try a new wardrobe or caffeine instead. If you, a cigarette addict, are considering e-cigs, know that replacing half your cigarettes by e-cigs will cut your risks in half. Safer for sure.
E-cigarette vapor inhalation is the breathing into your lungs of a mixture of chemicals. No good will ever come from repetitively inhaling chemicals into your delicate lungs. The liquids used to create e-cigarette vapor, propylene glycol and glycerin, are not water based and almost always containing nicotine when sold as e-liquids. But the problem chemicals within the vapor really arise from the application of Watts to the e-liquids, which creates a number of hazardous chemicals. Why are propylene glycol and glycerin used in the first place? They help nicotine dissolve into liquid form and were chosen because they also make e-cigarette vapor look like smoke when you exhale. When we studied these chemicals in lab, by buying them over the counter, putting them into common vape pens and e-cigarettes and inhaling them through syringes, we found that they are toxic to lung cells. But they required much higher levels to cause damage, as compared to cigarette smoke.
We have looked at the effect of e-cigarette vapor on airways, and have found that it can cause airways to spasm more, specifically indicating that asthmatics should avoid e-cigarette vapor in particular. We have looked at their effects on other organs in the body, and have found that inhaling e-ciagrette vapor into the lungs causes damage to distal organs as well.
So, overall, the studies that have come out and that are currently in progress show that inhalation of e-cigarette vapor is not benign. Also, we don't have convincing evidence that using e-cigarettes helps smokers quit in general. In fact, most of the data points to it increasing the nicotine addiction and making it harder for smokers to quit. But, most of the data thus far points to vaping causing fewer toxic effects as compared to cigarette smoking. So, if you were forced to inhale one or the other, you might want to choose e-cigarette vapor. But if you could totally avoid inhaling either, your lungs and other organs would be much happier for it.
Vaping Is Bad For Your Health
- “Listening to some e-cigarette advocates you would think that vaping was no more dangerous than inhaling purified water vapor. However, there is nothing natural about deeply inhaling a mist of propylene glycol and/or glycerin deeply into the lungs on a daily basis for years. The vaporization process involves a heating element which, especially in higher -powered advanced vaporizers, produces formaldehyde - a known carcinogen. Almost all e-juice flavors contain aldehydes, ketones, and natural extracts, which are felt to be safe when ingested. Nevertheless, the toxicity spectrum of the lung is very different from that of the gut. Many flavors, especially sweet and creamy flavors, contain diacetyl compounds which, when inhaled, are known to be a cause of serious lung disease among flavor manufacturing workers.”
- Robert K. Jackler, M.D. // Principal Investigator, Stanford Research Into the Impact of Tobacco Advertising, Stanford University School of Medicine
- “Big Tobacco and its allies have been trying to obscure the emerging science on the dangers e-cigarettes pose to public health. But claims that “vaping” is a healthier alternative to cigarettes, instead of a gateway, were disproven by a recent American Journal of Public Health study that found smokers who have used e-cigarettes are less likely to cut back on cigarettes in the future than smokers who haven’t used them.”
- Larry Cohen // Founder & Executive Director of the Prevention Institute
In the pharmaceutical industry, any drug that is used for human consumption has to undergo extensive toxicological testing before a series of clinical trials before it can be considered safe to use. To the best of my knowledge, e-liquids have not undergone any such testing, which to me is a major cause of concern. Given that the vaping industry is a multi-billion dollar industry, it seems reasonable that they should foot the bill to ensure that their compounds are safe. While, the constituents of e-liquids (e.g., propylene glycol, vegetable glycerin and flavors are on the GRAS (generally regarded as safe) list, GRAS compounds have only been tested for safety following oral ingestion little is known about their safety following inhalation. As a case in point, diacetyl, a butter flavor that is used in popcorn amongst other things, and has been shown to be present in e-liquids (2) causes bronchiolitis obliterans, deadly destruction of the lung, when inhaled.
Irrespective of the above comments, nicotine is a highly addictive compound that is toxic at high doses. People smoke and/or vape to get nicotine to the brain. The number of young people who vape has been dramatically increasing. However, in adolescents, nicotine exposure alters the development of the brain and changes how neurons connect: it lowers the threshold for addiction in adults. That is, developing young people who smoke will have permanently changed their brains in such a way as to increase their nicotine craving as adults.
Chronic inflammation underlies tobacco carcinogenesis and experimental studies show that e-cigarette vapor induces inflammation in the lung. Inhaled vapor also suppresses the lung’s immune response and increases bacterial virulence and viral load. While animal studies of toxicity are not definitive predictors of human risk, they do raise concern. Only time will tell the long-term risk of regular e-cigarette use. Bottom line is that no one yet knows the impact of inhaling the gaseous cocktail of e-cigarette vapor on the lung’s delicate bronchioles and alveoli, but there is ample reason for concern.
When Marlboro or Camel smokers satisfy their nicotine addiction with vapor products instead of burning tobacco leaf, it is likely to be beneficial to their health. Unfortunately, studies have yet to show much effectiveness of e-cigarettes on smoking cessation. Paradoxically, by using e-cigarettes in places where smoking is prohibited, e-cigarettes may actually strengthen a smoker’s nicotine addiction. While advances in technology and e-juice chemistry may someday improve cessation efficacy, today’s e-cigarette devices do not provide the dramatic spike of nicotine the brain receptors of addicted smokers crave.
Concerns over the long term health consequences of e-cigarette use raise important public policy implications. The foremost policy goal is to protect adolescents from adopting e-cigarettes as studies show that they may be a gateway to lifelong nicotine addiction. CDC data shows that between 2011 and 2015, use of e-cigarettes among American high school students rose dramatically (more than 10 fold - from 1.5% to 16.0%). An estimated 3 million American high school and middle school students are using e-cigarettes. In 2015, more high school students actually used e-cigarettes than cigarettes (16% vs. 9.3%). The auspicious decline in youth cigarette use of recent years has leveled off, suggesting that early e-cigarette adopters may be transitioning to traditional combustible cigarettes. Disturbingly, due to soaring e-cigarette use, nicotine product consumption among American high school students has actually increased to over 25% over the last few years.
The FDA recently deemed e-cigarettes to be tobacco products and thus within their jurisdiction. The agency is considering measures to constrain youth targeted marketing and also a ban on flavors other than tobacco (thousands of flavors are on the market including glazed donut, gummy bear and piña colada) both due to their differential appeal to youth and potential toxicity.
Nicotine is a dangerous and potentially lethal product in the hands of a young child. Many e-cigarettes lack warning labels and childproof packaging. Inadvertent nicotine exposure to young children is a risk. Reports of poisoning from nicotine toxicity tripled to U.S. Poison Control centers between 2012 and 2013 (Bassett et al., 2014).
In 2010, the FDA attempted to regulate e-cigarettes. E-cigarette companies sued the FDA to prevent the regulations in federal court and won. As a result, the ruling of the court determined that e-cigarettes that do not make therapeutic claims will be regulated as tobacco products. If a therapeutic claim is made, such as that an e-cigarette can help you quit smoking, then the manufacturer must first prove through a series of clinical trials that their product is safe and effective (ALA, 2016). The FDA has recently issued a deeming rule to regulate e-cigarettes. However, it could be a couple years before e-cigarette companies are compliant.
Electronic cigarettes contain fewer chemicals in the vapor than a traditional tobacco cigarette, but still toxic substances. Studies have shown that e-cigarettes contain carcinogens such as acrolein, formaldehyde and acetaldehyde nitrosamines. The toxic substance diethylene glycol and other substances unsafe for human consumption have been identified in e-cigarette vapor. Long-term health effects of e-cigarettes are unknown, however data has shown that e-cigarette vapor does cause short-term health effects similar to cigarettes (Avdalovic, 2012; Vardavas et al., 2012). The effects of second-hand vapor exposure has been of question. Preliminary studies have demonstrated nicotine exposure to bystanders from e-cigarette vapors which could be problematic to vulnerable populations such as children and pregnant women (Czogala et al., 2014).
E-cigarettes have not been approved as a smoking cessation aid by the FDA. There are several FDA-approved quit aids available for smokers who want to quit. FDA-approved quit aids have been shown to be a safe and effective way to quit smoking. Efficacy is increased when paired with a behavioral counseling program.
I was involved in the work to pass the nation’s first multi-city smoking ban — in Contra Costa County, California — and we saw the same tactics from the tobacco industry then: denying that its products were killing off customers, and sowing doubt about solid science, in an attempt to stall anti-tobacco regulations that swept the country and saved millions of lives.
California, along with eight other states, has connected the dots, and now classifies e-cigarettes as tobacco products, making them subject to smoke-free laws, age restrictions and other rules governing tobacco products. This came on the heels of a report issued last year by the California Department of Public Health (CDPH) shedding light on the public health risks of e-cigarettes. The risks include:
- The vapor alone contains at least 10 toxic chemicals known to cause cancer or birth defects, including benzene, formaldehyde, and lead.
- E-cigarettes contain nicotine, a neurotoxin that affects the cardiovascular and central nervous systems, causing blood vessels to constrict and raising blood pressure. Nicotine also adversely affects maternal and fetal health during pregnancy, contributing to low birth weight, preterm delivery, and stillbirth.
- In California, e-cigarette poisonings of young children tripled in 2014 alone. From 2012 to 2013, the number of calls to poison control centers involving e-cigarette exposures rose from 7 to 154 in children five and under.
- Using an e-cigarette with nicotine for just five minutes causes similar lung irritation and inflammation, and has a similar effect on blood vessels, as smoking a traditional cigarette.
Without strict limits on the marketing and sale of e-cigarettes and the extension of smoke-free policies to cover them, we will see more children getting hooked on nicotine, more poison control emergencies, and a mounting burden of preventable illness and injury. That’s why the FDA prohibits retailers from selling e-cigarettes to people under age 18, noting that e-cigarette use among high school students jumped to 16% in 2015 from 1.5 percent in 2011. The truth is out: vaping is not safe.
- First and foremost, there is no safe form of tobacco. There is no known correlation as to how much tobacco exposure (whether vaped, smoked, chewed, sniffed or exposed secondhand) will lead to disease.
- Electronic cigarettes (e-cigarettes) were declared tobacco products by the U.S. Food and Drug Administration (FDA) on May 5, 2016.
- Toxicologists have warned that vaping or e-liquids — nicotine in liquid form — pose a significant risk to public health. It also has been found e-cigarettes contain detectable levels of known carcinogens and toxic chemicals, as well as inconsistent levels of nicotine. The e-liquid is derived from insecticide grade nicotine - the exact same chemical found in insecticide poisons. Studies by leading labs have found inconsistent levels of nicotine with approximately 10% of the toxins and carcinogens found in smoked tobacco. (Notice I said "insecticide" grade as compared to pharmaceutical grade purified nicotine found in nicotine gum, smoking patches, etc.).
- E-cigarette vapor contains formaldehyde. Formaldehyde is present as a dissolved gas in the water-based solution called formalin, which is used during embalming processes as a disinfectant and preservative.
- There is a significant risk of explosion and fire involving an e-cigarette. There is a growing body of evidence that shows fires, explosions and significant burns associated with the use of e-cigarettes.
- It goes without saying that it’s important to put a stop to the ease of access of e-cigarettes by children and young adults. The FDA is striving to do this — on Aug. 8, 2016, the FDA began regulating e-cigarettes, and it became illegal nationwide to sell cigars, hookah tobacco and e-cigarettes to anyone younger than age 18. Watermelon and blueberry are not the flavors a college student would buy.
- E-cigarettes have not been approved by the FDA as a safe or effective method to help smokers quit.
- they are properly regulated;
- found to be effective at helping smokers quit completely; and
- are responsibly marketed to adult smokers.
In any event, they are not safe, especially for kids. Kids should not use any tobacco products, including e-cigarettes. Unfortunately, youth use of e-cigarettes in the United States has skyrocketed in recent years. The CDC’s latest survey showed that almost one-quarter of all high school students were current (past-month) users of e-cigarettes in 2015, compared to 10.8 percent who smoked regular cigarettes. That trend is not surprising as e-cigarettes have been irresponsibly marketed using tactics long used to promote regular cigarettes to kids and are sold in an assortment of kid-friendly flavors such as gummy bear and cotton candy.
E-cigarette use can put kids at risk of nicotine addiction. The CDC has warned that nicotine exposure could also harm adolescent brain development and lead to sustained tobacco use. Some studies have also found other harmful or potentially harmful chemicals and toxins in some e-cigarettes, even if at lower levels than cigarettes. Further, while some of the flavorings used in e-cigarettes might be safe for ingestion, they are not necessarily safe when inhaled. Researchers have raised concerns that the chemical flavorings found in some e-cigarettes and e-liquids could cause respiratory damage. Our kids should not be the guinea pigs while we learn more about the health effects of e-cigarettes.
As for the impact on current smokers, the evidence to date in the U.S. is limited and inconclusive as to whether e-cigarettes are effective at helping smokers quit. The CDC has reported that three out of four adult e-cigarette users are also cigarette smokers. The U.S. Preventive Services Task Force recently conducted a thorough evaluation of the science and concluded that “the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation…” Without regulation, manufacturers have produced many e-cigarette products that don’t help smokers quit and frustrate those who try to use them to quit.
The Food and Drug Administration recently issued long-overdue regulations for e-cigarettes that prohibit sales to children under 18 and will help answer the many questions about these products. Under these rules, the FDA will be able to learn about the contents and health effects of e-cigarettes and evaluate the evidence whether these products can help smokers quit. Effective regulation by the FDA is critical to minimizing the risks posed by e-cigarettes and maximizing the potential benefits.
The Jury’s Still Out
- “Vaping exclusively (without smoking any cigarettes) is almost certainly less harmful than continuing to smoke conventional tobacco cigarettes, though the data to prove this hypothesis do not yet exist because e- cigs are such new products that entered the market without regulation (until very recently).”
- Nancy A. Rigotti, M.D. // Director of the Tobacco Research and Treatment Center at Massachusetts General Hospital & Professor of Medicine at Harvard Medical School
- “The safety of vaping is not well established. There is no evidence showing that vaping is safe and that it does not have any significant health effects. No well-controlled short-term or long-term studies have been conducted to evaluate the health effects of vaping. While the results of some early studies have suggested that some of the acute cardiovascular and respiratory effects seen with smoking and not seen with vaping, it is unclear whether the health risks associated with repeated and frequent vaping are minimal.”
- Aruni Bhatnagar, Ph.D. // Smith and Lucille Gibson Chair in Medicine, University of Louisville
Vaping exclusively (without smoking any cigarettes) is almost certainly less harmful than continuing to smoke conventional tobacco cigarettes, though the data to prove this hypothesis do not yet exist because e-cigs are such new products that entered the market without regulation (until very recently). However, most people using e-cigs appear to be continuing to smoke some cigarettes, often to reduce harm. It is not clear how much (if any) harm reduction results from this dual use. Finally, we are still learning what, if any, new risks the contents of e-cigs or process of vaping might produce. If harmful, how harmful vaping itself is depends on how long it is done. A smoker who switches totally to e-cigs for a short term and then quits vaping probably runs very little risk from vaping even if vaping has some inherent risk. If vaping has any risks, it will be larger for individuals who vape indefinitely, of course. And risk will be even higher for those who continue to smoke cigarettes while also vaping.
Although it is clear that several of the carcinogenic substances present in cigarette smoke are absent or marked diminished in e-cigarette aerosol, in the absence of direct evidence on the chronic effects of vaping, it is difficult to ascertain the relative safety of e-cigarettes. In addition to nicotine, e-cigarettes frequently contain propylene glycol and vegetable glycerin and a variety of flavors. The toxicity of these chemicals has not been tested. Propylene glycol and glycerin can be irritants and upon heating break down in chemicals such as aldehydes that have been shown to have adverse cardiovascular and respiratory effects. The flavors added to e-cigarettes are generally regarded as safe when consumed with food, but it is not known whether their toxicity is enhanced upon heating and whether repeated inhalation of these flavors could have untoward health effects. Moreover, most e-cigarettes contain nicotine, which is a potent toxin and even at concentrations present in e-cigarettes and combustible cigarettes can increase heart rate and blood pressure and compromise the dilation of blood vessels.
But perhaps the greatest danger of vaping is the possibility that widespread use of e-cigarettes could lead to social renormalization of smoking and potentially recruit new generations of users not only to vaping, but to smoking combustible cigarettes as well. Such developments threaten to erode the gains made by decades of public health campaigns, because social acceptance of vaping could prevent smokers from quitting; but more importantly, it could recruit a whole new generation to a lifetime of nicotine addiction.
However, the scientific community is only beginning to look into the long term impact of vaping on health and, because there are so many vaping products on the market it is difficult to make a blanket statement about the safety of all vaping devices. Some researchers in the public health arena are concerned about claims that vaping is 95% safer than smoking cigarettes, noting that those claims are educated guesses at best. And while vaping may be safer than using combustibles, this does not imply they are a hundred percent safe.
Nicotine is not benign, and even if it was, addiction itself harms an individual, even if that harm is solely financial. It is immoral for any person or corporation to profit from causing someone’s lifetime addiction.
For this reason, the role of the tobacco industry in this debate is a bit worrisome. A number of corporations that in the past focused on selling cigarettes are now marketing and selling the entire gamut of nicotine delivery products, including traditional combustible products such as cigarettes, various forms of oral tobacco, alternative nicotine delivery products such as e-cigarettes, and products that are intended to assist with cessation such as NRTs. While it would be useful for addicted smokers who cannot quit to have access to safer nicotine delivery products, it would not be ethical or good for overall public health to flood the market with vaping devices that could increase the prevalence of nicotine addiction among current non-smokers and future generations.
It is clear that vaping can have potentially both positive and negative impacts on public health. Policy should seek to mitigate the negatives and enhance the positives, and the public health community needs to have a robust discussion on how to accomplish this. Strong anti- or pro-vaping positions in the public health community make this dialogue more difficult, but from following these debates, I recognize that views from both sides come from a sincere desire to avoid harm.
In determining policy, governments and the public health community should consider the following:
- Policy should be based on science (both medical and epidemiological) in order to determine the safety of the product, its effectiveness as a cessation tool, and its impact on nicotine initiation.
- Including vaping restrictions in most smoke free policies makes sense.
- The marketing of vaping products to non-smokers is problematic and should be addressed. Children should not be targeted, including with candy flavors, and restrictions similar to those for combustible tobacco products should be put in place. Initiation to nicotine is not good for public health, and corporations’ intent to addict next generations to nicotine is unethical, even if the delivery mechanism is safer than combustibles.
- The burden of proof for health claims should be borne by manufacturers of vaping devices.
The bottom line is that there is much that we still don’t know about these products. As health professionals, we caution their use and strongly advocate sound scientific investigation in order to better understand the potential harms that may come from them.
Image: Jennifer Borton / iStock.
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