Up in Smoke: Dangers of Vaping and E-Cigarettes
Dr. Laurie A. Romig, MD
Most of us have heard about the on-going epidemic of fatalities related to the use of opioid drugs, and prescription drug abuse, but another public health emergency is gathering momentum in the world of e-cigarettes. The increasing popularity of vaping, alongside its connection to a pattern of severe lung damage among its users, is a major source of concern when addressing the full scope of the dangers of vaping. As of November 2019, the Centers for Disease Control and Prevention (CDC) has identified 42 deaths and 2,172 cases of E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI). While there is a lot of formal research to be done to understand all the short and long-term effects of EVALI and other complications related to e-cigarettes and vaping, including trying to answer the question of “is vaping addictive”, we do have some information to help you to understand, and properly navigate known issues and hazards.
The Known and Unknown Risks of Vaping
E-cigarettes and vaping devices are collectively known as Electronic Nicotine Delivery Systems, or ENDS. There are many legally manufactured ENDS products with relatively minimal federal or state oversight, but there are also many, many illegal and illicit devices and liquid preparations available to the public. For example, as of 2014, there were more than 7,700 flavorings available for use with ENDS devices. This diversity of materials makes it difficult to thoroughly understand related health issues, and the full scope of the dangers of vaping. To put it in perspective, today’s understanding of ENDS uses and potential complications is probably at about the same level as knowledge about conventional tobacco and nicotine use was in the 1970s.
The e-cigarette was invented in 2003, primarily as part of the search for a safer delivery system for nicotine. Conventional cigarette smoke is known to contain a large number of products of combustion (burning), many of which are known to cause various cancers or other types of damage to the body. E-cigarettes and vaping products attempt to address these dangers of vaping at least partly by avoiding the actual burning of tobacco leaves, using lower temperatures and liquid extracts that can still release nicotine.
Nicotine and other additives are found in the resulting vapor, so it’s possible that second-hand smoke effects may still be an issue. Unfortunately, the short and long-term effects of specific components of the vapor are not yet well understood. Research does seem to show that use of ENDS decreases the incidence of lung cancer compared to conventional cigarette smoke inhalation, but many other effects are poorly understood and possibly very risky.
Is Vaping Addictive?
Another complicating factor is that, in some cases, the contents of the fluid (also known as e-juice) can be modified by users or distributors, uncovering new risks of substance abuse in the process. These modifications can be used to alter amounts of nicotine, flavorings, and the psychoactive component of marijuana, THC, which adds the risk of marijuana abuse and dependence. Researchers know that marijuana use can lead to abuse, dependence, and addiction, regardless of the method of consumption, so it is likely that vaping marijuana is an addictive habit. Among other problems, THC can permanently affect brain development not just in children and juveniles, but in young adults into their mid-20s.
The risk of nicotine addiction is also very present among people who vape and use e-cigarettes. Many vaping liquids contain high levels of addictive nicotine; for example, single JUUL brand vape cartridges contain the same amount of nicotine found in a full pack of conventional cigarettes. Meaning not only is the risk of nicotine addiction still present, but new users are consuming much higher volumes of nicotine, more quickly.
The Concerning Patterns of Younger Vaping Demographics
Middle school and high school students are an especially concerning group of ENDS users who may be putting themselves in danger of both long and short-term health problems. Here are some interesting numbers:
- In 2017, the Food and Drug Administration (FDA) released survey statistics showing that more than two million middle and high school students were using ENDS.
- Approximately 80% of these users believed that ENDS use was either totally or relatively risk-free.
- Between 2017 and 2018, high school student use nearly doubled and middle school student use increased by 700%.
- Of students who use ENDS but not conventional tobacco, 72.2% of high school students and 59.2% of middle school students use flavors.
Many people feel that advertisements for various ENDS products have been designed to appeal specifically to minors, even though a growing number of states specifically forbid sales to minors. Others feel that the development of flavored e-liquids specifically targets young people, especially flavors that make vaping taste sweet like fruit or candy. The leading manufacturer of e-cig and vaping products, JUUL, has very recently agreed to stop manufacturing or distribution of flavors other than tobacco and menthol. Media coverage includes a growing number of student ENDS users who have suffered various complications or who agree that student-focused marketing is a factor in their decisions to use ENDS.
How Vaping Damages Your Lungs
While there had been some concern over unknowns associated with e-cig or vape use, the factor that has recently turned up the volume has been the recognition of a pattern of extremely serious and sometimes fatal lung problems in some ENDS users. This dangerous side effect of vaping, has been named “E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)”. In October 2019, 1,299 cases of EVALI were reported, with 26 deaths. About one month later, the case count was up to 2,290 with 47 deaths and an increase of 118 cases and 5 deaths in just one week.
EVALI patients mostly have breathing-related symptoms, but they may also have fever, chills, weight loss, and nausea/vomiting, abdominal pain, or diarrhea. Some patients require a ventilator and ICU care; others may be treated without admission to the hospital. One patient even required a double lung transplant. ENDS users who are over the age of 50, who are pregnant, or who have heart or other lung disease are at higher risk.
What do these EVALI cases have in common?
- All have been in people who use e-cigarettes or vape pens
- 85% vaped THC
- 36% were between 18 and 24 years old
- Compared to ENDS users who have not had EVALI, these lung injury patients had higher odds of:
- Using only THC products
- Frequent use (five or more times per day)
- Obtaining vape fluid from informal sources (not legally obtained or regulated)
- Use of “Dank Vapes”, an illicit THC product that comes in 31 flavors
What Causes EVALI?
The cause of EVALI continues to be uncertain, but several possibilities have been proposed. The current leading thought is that inhalation of vitamin E acetate causes the lung damage. The chemical is often used in the ENDS industry as a thickening and butter-flavoring agent. It is harmless when eaten but causes lung tissue damage when inhaled. Another chemical, diacetyl, is a leading suspect in the dangers of vaping. There may be other causes or factors that combine to cause EVALI. It appears that at least in serious cases, lung tissue is destroyed and function can’t be recovered.
There may be other ingredients of e-liquids that cause medical problems or injuries related to the heating process used. Further experience and research are required.
The Additional Risks of ENDS
Here are a few additional dangers of vaping that users put themselves at risk of experiencing:
- Becoming addicted to nicotine or worsening already established substance abuse
- Although the e-cig/vape concept was created with the purpose of helping people to stop or decrease conventional smoking, the current vaping liquids often have higher levels of nicotine than regular cigarettes.
- Heart problems
- ENDS effects on the heart may be mixed. The main effect on the heart may be due to the nicotine content, just like conventional smoking. These include bad effects on cholesterol and blood sugar and decreasing blood flow in the heart even more than regular cigarettes. Other studies have had conflicting results.
- Pediatric exposure
- Between 2013 and 2017, over 4,000 children under the age of five were evaluated by Poison Control Centers or emergency departments for nicotine exposure related to ENDS. Over 90% of these were due to swallowing e-liquids. Hundreds of cases needed emergency department evaluation and treatment each year. Fortunately, that number is dropping slightly now because of special state and federal legislation that requires child-resistant packaging and special labeling of nicotine-containing products.
Where Do We Go From Here?
This crisis is so significant that the CDC Emergency Operations Center has been activated to the same level that has been employed for public health emergencies like the COVID-19 and hurricanes. Congress and the White House are working on possible legislative packages and further study, with one of the main goals to be establishing or increasing regulations for the industry. One example of action has been working towards banning the sales of flavored e-liquids, at least to minors. Public education will also be critical.
Advice for individuals and medical providers to follow comes from the CDC and is updated as further information becomes available. The current recommendations of the CDC for the general public include:
- Avoid vaping, especially if you aren’t a smoker. Consider completely avoiding e-cigarettes or vaping products all together.
- Children, young adults, and pregnant women should not smoke or vape at all.
- Avoid vaping THC, even if the product is legal.
- A very high percentage of EVALI patients vaped THC.
- Don’t use modified or street-bought vaping products.
- You just don’t know what you’re really getting.
- A very high percentage of EVALI patients use modified or street-bought products.
- Do not use products that contain vitamin E acetate.
- Don’t use e-cig/vapes as part of an attempt to stop smoking.
- You could be exposing yourself to even higher levels of nicotine and other harmful chemicals.
- Stick to FDA-approved nicotine replacement products.
Our understanding of ENDS-related issues is progressing rapidly. Recommendations may change, even sometimes on a monthly basis. Whether you are concerned for yourself or someone else, you can keep your information up to date via social media and news sources, but for the most accurate official information, go to the CDC website. If you’d like to see more in-depth information, click on any of the underlined links in this article. You can also read our resource guide on marijuana abuse, if you would like to learn more about the dangers of vaping THC and marijuana overdose symptoms.