E-Cigarettes: A Hazard or a Help?

Abstract

A global debate has arisen regarding the relative benefits and harm resulting from the use of electronic cigarettes (“e-cigarettes”). In some countries, such as the United Kingdom, the use of e-cigarettes (“vaping”) has been shown to help reduce addiction to combustible tobacco cigarette (“smoking”), which represents the leading preventable health hazard in many countries. In contrast, in other countries, such as the United States, e-cigarettes, which have attracted many adolescents and young adults who would not otherwise have started to smoke, represent an alternative delivery vehicle for nicotine or cannabis (marijuana) by expanding their markets, reducing nicotine cessation rates by means of a more convenient, healthier, and less offensive product. Although considered less harmful health-wise than smoking, the expected net effect of vaping remains controversial, as sufficient experience has not yet been accumulated to confirm the health impacts, especially over the long term. Nevertheless, viewed by themselves, e-cigarettes do represent a health hazard, with growing information regarding their adverse effects. The stakes of this debate are high—for individuals, society and the e-cigarette, tobacco, insurance, and health care industries. After highlighting the current use of e-cigarettes by adults and adolescents, this article summarizes current issues associated with e-cigarettes, highlighting their health effects; nicotine and addiction; initiation; smoking cessation and harm reduction; gateway to smoking; modifications; flavorings; secondhand aerosol; and new product innovations. It discusses the sources of disagreements and reactions from regulators and life insurers. In addition, the modeling, estimates, and uncertainties associated with mortality resulting from vaping are addressed. For life and health insurance, actuaries are assessing whether to treat e-cigarette users in a manner similar to those who smoke combustible tobacco cigarettes.

Discussions on this article can be submitted until October 1, 2020. The authors reserve the right to reply to any discussion. Please see the Instructions for Authors found online at http://www.tandfonline.com/uaaj for submission instructions.

Notes

1 A tank of chemicals used in vaping is sometimes referred to as a “pod..”

2 Although the modern e-cigarette was introduced in Europe and North America in 2006, prior attempts to develop a similar device were made, as indicated at http://casaa.org/historical-timeline-of-electronic-cigarettes.

3 Flavorings are also included in some combustible tobacco cigarettes.

4 A typical concentration in combustible tobacco cigarette in the United States is 16 mg/ml (Donny et al. 2015). However, the range of concentration is wide (from 6 to 59, depending upon country and type of e-cigarette. A few countries limit this concentration to 20 mg/ml.

5 These can deliver tetrahydrocannabinol (THC), the main active ingredient in marijuana that delivers a high, or the cannabidiol (CBD), an active ingredient in cannabis/marijuana. CBD and butane hash oils are known as “dabs..” In 2019 it has been found that some black-market operators have added thickening agents (such as vitamin E acetate, an oil derived from vitamin E to dilute solutions) to fill vape cartridges. Vitamin E acetate is a common nutritional supplement and is used in topical skin treatments. Although not known to cause harm when ingested or applied to the skin, it could be hazardous to the lungs if inhaled.

6 Although referred to in this article loosely as “e-cigarettes,,” these are a family of electronic devices with similar characteristics, as indicated in Figure 1, which includes e-pipes, e-cigars, and e-shishas.

7 Primarily cigarettes, although references to combustible tobacco cigarettes here also include cigars, pipes, hookahs, and smokeless tobacco products.

8 More detailed analyses of the aerosol or smoke generated by e- and combustible tobacco cigarettes has added to the list of typical elements found in tobacco smoke, which include sodium, iron, aluminum, potassium, copper, magnesium, zinc, chromium, and manganese. The elements included in e-cigarette aerosol can also contain boron, silicon, calcium, sulfur, tin, barium, zirconium, strontium, titanium, and lithium—many of which have documented adverse effects on the cells of the respiratory system.

9 The extent of formaldehyde, which has been shown to be unhealthy, generated by vaping has proven controversial. For example, Jensen et al. (2015) found formaldehyde-containing hemiacetals that can be formed during the vaping process, while J. L. Nitzkin, K. Farsalinos, and M. Siegel indicated that if this occurs it is easily detectable by a user as a result of an exceedingly unpleasant burning taste (“dry puff”—a result of smoking an e-cigarette with a minimal amount of e-liquid). The vaper will normally discontinue using that unit if this occurs; alternatively, the interval between puffs will be increased. This may prevent exposure to excessive formaldehyde formed by the overheating of the e-cigarette’s liquid. Nevertheless, all 42 samples of e-liquids assessed in Varlet et al. (2015) were found to contain some formaldehyde, and Klager et al. (2017) found that under typical conditions, the formaldehyde coming out of an e-cigarette in each of 24 flavors tested can exceed ceiling limits (a level in the air not allowed in the workplace in the United States, with at least one aldehyde and/or flavoring chemical on either the Federal Emergency Management Agency (FEMA) list of "High Priority Chemicals" or the Food and Drug Administration (FDA) Harmful and Potentially Harmful Constituents list.

10 First generation e-cigarettes closely mimicked the look and feel of combustible tobacco cigarettes.

11 Produced by Juul Labs, Inc., which in 2018 had about 70% market share of the tracked e-cigarette market in the United States. In 2018, a starter kit cost $35 and a pack of four nicotine refill cartridges cost $16.

12 Nicotine salts, not present in combustible tobacco cigarettes, are organic and arise from nicotine that bonds with benzoic acid in the tobacco plant. Other brands use alternative acids. Their use provides a concentration in blood plasma in the time comparable to combustible tobacco cigarettes. Nicotine salts are also lipid soluble, i.e., they can cross the blood–brain barrier, and therefore trigger a dopamine release more efficiently than other e-cigarettes. The greater nicotine concentration provided, unlike other tobacco products without nicotine salts, is not accompanied by a throat burn.

13 “Mordor Intelligence”. Mordorintelligence.com. “E-Cigarette Market - Growth, Trends and Forecast (2019–2024); IMARC Group. "E-Cigarette Market: Global Industry Trends, Share, Size, Growth, Opportunity and Forecast 2019–2024.”

14 Harm as used in this article refers to an adverse effect on a person’s health (or, ultimately, mortality). Other harm reduction tools include inhalators, nicotine patches, nicotine gum, lozenges, prescription drugs, and reduced-nicotine tobacco products. Often, multiple smoking cessation approaches are used.

15 Adapted from electronic publication of Addiction.

16 A discussion of e-cigarette-related accidents is included in the Appendix.

17 PHE (2015) indicated that some flavorings in and constituents of e-cigarettes may pose risks over the long term, but that the 5% estimate should be more than enough to cover this risk.

18 A biomarker is a characteristic that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.

19 A nationally representative population-based longitudinal cohort study to collect data on uses of tobacco products, health outcomes, risk perception, and attitudes of about 32,000 participants on a self-reported basis with data collected between 2013 and 2014. It was reported on by Bhatta and Glantz (2019).

20 A disturbance in the balance between the production of reactive oxygen species (“free radicals”) and antioxidant defenses.

21 The Committee did not observe a statistically different effect on vitamin E levels or FMD, with a smaller impact than combustible tobacco cigarettes on levels of soluble NOX₂-derived peptide, 8-iso-prostaglandin F2a, and nitric oxide bioavailability.

22 Chemically reactive species, containing oxygen. This is formed as a by-product of normal metabolism of oxygen and has a role in signaling and homeostasis. During times of environmental stress, these can increase dramatically, which can result in significant damage to cell structures.

23 The Heart e-Heart Study is an ongoing Internet-based study, with exposures between March 2013 and March 2017, which included 573 vapers, 1693 smokers, and 514 dual users of a total population of almost 40,000.

24 Tests of mice subject to vaping over a 12-week period, which, according to the authors, is equivalent to 10 years of light vaping in humans.

25 A process of converting organic compounds into nitroso derivatives, i.e., compounds containing the R-NO functionality within a molecule. Nitrosamines are formed by the nitrosation (addition of an N = O group) of secondary and tertiary amines (in tobacco—nicotine, nornicotine, anabasine, and anatabine, referred to as alkaloids, an organic base that contains nitrogen).

26 Also involved in addictive drug use.

27 Addiction to or at least habit formation.

28 Sponsored by the National Cancer Institute, based on a subsample of the U.S. Census Bureau’s Current Population Survey.

29 Certain contaminants, counterfeit substances or cartridges may prove harmful. As of October 2019, they have been blamed for a large portion of observed acute respiratory injuries/illnesses that developed from vaping in the United States in 2019. A large percentage involved THC, but not all e-cigarettes containing THC are through mods—several e-cigarette companies are selling vaping products that contain thickening agents that modify the amount of THC in vaping liquid. A counterfeit product is usually purchased on the black market—a distributor buys empty cartridges, fills them with a mix with THC or nicotine, and then applies a “brand” label with obtained packaging.

30 Vaporizing the e-liquid at high temperatures by dripping a couple of drops of e-liquid directly onto an atomizer’s coil and then immediately inhaling the aerosol that is produced.

31 The Flavor and Extract Manufacturers Association of the United States have suggested adding a warning about diacetyl and certain other flavoring chemicals that reads “Handling of this flavor that results in inhalation of fumes, especially if the flavor is heated, may cause severe adverse health effects.” Diacetyl has been linked to popcorn lung.

32 Pulegone is a constituent of oil extracts prepared from mint plants, including peppermint, spearmint, and pennyroyal, is a carcinogen that causes hepatic carcinomas, pulmonary metaplasia, and other neoplasms on oral administration in rodents.

33 A substance used to reduce the loss of moisture.

34 HNB products contain a small heater that warms a tobacco stick to a temperature between 50ºC to 350ºC, compared to about 800ºC for combustible tobacco cigarettes.

35 The only studies that have been published have been prepared in conjunction with the HNB industry.

36 Almost all studies available to date have all been produced or sponsored by entities with a potential financial conflict of interest.

37 Performed or taking place in a test tube, culture dish, or elsewhere outside a living organism.

38 The Vapor Association, which represents mostly mom-and-pop shops, indicated in September 2019 that these involve about 166,000 jobs in the United States.

39 An independent panel, reporting to the U.S. Agency for Healthcare Research and Quality (AHRQ).

40 No safe tolerance levels for these toxicants in aerosols have been agreed upon.

41 Twelve from Europe, six from Asia, two from North America, and one each from Africa and Oceania: Algeria, Australia, Azerbaijan, Canada, Finland, Germany, Hungary, Iran, Israel, Italy, Japan, Lebanon, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Turkey, the United Kingdom, and the United States. The author thanks those who responded and members of the IAA Mortality Working Group for their assistance.

42 The FDA, in partnership with the Surgeon General, and together with Scholastic, planned to distribute youth e-cigarette prevention posters and lesson plans to every high school in the United States, with additional resources planned for middle school educators in the 2019–2020 school year. The FDA has made available resources for doctors, youth groups, churches, state and local public health agencies, and others on the dangers of youth e-cigarette use and has undertaken efforts to further the discussion and understanding around how to help children and adolescents who are already addicted to e-cigarettes to quit.

43 Various studies have been conducted to determine the effectiveness of alternative approaches to reduce tobacco prevalence. As indicated in Palali and van Ours (2019), the effectiveness of nonprice antismoking policies has been inconclusive—some studies have found that tobacco control policies reduce smoking, while other have not. Their study of 11 European countries suggested such constraints had no significant effect on smoking initiation. However, comprehensive cessation policies have been shown to be effective in some situations.

44 Although this appears most apparent to date in the United States, it is difficult for the author to imagine that this attraction will be limited to that country in the future.