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Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 183-185

Electronic vaping: Is it harmless or a snake in the grass?

Department of Medicine, University Sleep Disorders Center, College of Medicine, King Saud University; The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation, Riyadh, Saudi Arabia

Date of Web Publication4-Oct-2019

Correspondence Address:
Ahmed S Bahammam
xUniversity Sleep Disorders Center, College of Medicine, King Saud University, Riyadh 11324
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_41_19

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How to cite this article:
Bahammam AS. Electronic vaping: Is it harmless or a snake in the grass?. J Nat Sci Med 2019;2:183-5

How to cite this URL:
Bahammam AS. Electronic vaping: Is it harmless or a snake in the grass?. J Nat Sci Med [serial online] 2019 [cited 2023 Feb 9];2:183-5. Available from: https://www.jnsmonline.org/text.asp?2019/2/4/183/268542

The past few weeks witnessed the death of a few people who were smoking electronic cigarettes (ECs) in the United States.[1],[2],[3],[4] Deaths included different age groups, including middle-aged individuals. One of them was a 50-year-old woman who had a history of health problems. She became seriously ill shortly after she started using EC and her symptoms progressed rapidly.[1] The US Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and state health departments are investigating this outbreak; however, no definitive cause could be found.

Smoking ECs is also known as “vaping,” which may include the standard ECs, electronic shisha (hookah), electronic cigar, and electronic pipe.

Unfortunately, ECs have been promoted among conventional cigarette (CC) smokers as a useful tool that helps in stopping CC smoking and have become the most popular smoking-cessation aid in some countries like England.[5] In addition, ECs have been promoted, particularly, among youngsters by the manufacturers and unfortunately, by some investigators as harmless despite lack of FDA approval of using them as a smoking-cessation aid.[6],[7] As a result, the usage of ECs has increased globally, mainly among teenagers. Several studies have demonstrated that ECs smoking has increased over the past decade among both adolescents and adults.[8] Recent data from the US revealed that 4% of middle school students and 11% of high school students reported having tried ECs.[9] Reports from the UK of 60,000 youngsters, aged 11–16 years, demonstrated that regular ECs use is 3% and ever-use ranges from 7% to 18%.[10] Not surprisingly, as a result of promoting ECs among youth, data from approximately 25,000 young individuals in the US who were surveyed in 2012 revealed that almost 30% of adolescents in the US consider ECs as less harmful than CCs.[11] A recent study in Saudi Arabia reported that nearly 80% of University students smoke ECs occasionally, and 20% use ECs daily.[12] Interestingly, 43% of the sample mainly used ECs as an aid for CC smoking-cessation.[12]

In vivo and in vitro animal studies reported that ECs induced cytotoxicity to various cell lines, resulting in cell death, reduced cell proliferation, and augmented oxidative stress.[13],[14],[15] Nevertheless, the cytotoxic activities of ECs and effects on gene expression were lower than CC.[16],[17],[18] In an industry-sponsored study, a 7-month exposure of ECs vapor inhalation in mice caused nicotine-dependent lung inflammation and emphysema.[19] Moreover, in a mouse model study, a 4-week exposure to ECs vapor reduced macrophage and neutrophil antimicrobial function and increased susceptibility to lung infection.[20]

ECs contain several toxic constituents including, nicotine, propylene glycol and vegetable glycerin, oxidizing chemicals, formaldehyde, particles, and metals such as cadmium, nickel and chromium, and flavors.[8] It is possible that the constituents and probably the toxicity of ECs aerosols differ significantly across different models of EC devices and liquids.

Short-term experimental human studies revealed acute cardiovascular changes of nicotine stimulant effects; nevertheless, there is still a lack of studies evaluating the long-term effects of ECs.[8]

A major notion among ECs users is that ECs help in smoking-cessation of CC. However, is there good evidence to support this notion? Previous studies that reported improvement in smoking-cessation were observational. Such a design has apparent limitations and cannot be used as strong evidence to rule out the effects of self-selection. A new task force report by the European Respiratory Society indicated that the evidence supporting the efficacy of ECs as a quitting tool is limited and further studies are needed, particularly, studies that compare ECs with licensed smoking cessation treatments.[8] The National Health and Medical Research Council of Australia released a statement on ECs in 2017, stating that there is currently inadequate evidence to support the conception that ECs can help smokers to quit.[21] Moreover, the report indicated that there is some evidence from longitudinal data to suggest that ECs usage in nonsmokers is associated with a potential increase in CC smoking.[21] A systematic review of health effects of ECs that was prepared for the World Health Organization concluded that “ECs are highly addictive and there is insufficient evidence on the safety of long-term use of nicotine.”[22] In fact, the use of ECs has globally increased dual smoking of CC and ECs. Two surveys in the US and Poland reported dual smoking on ECs and CC in more than half of young ECs users.[23],[24]

Another misconception among youth in different parts of the world, including Saudi Arabia, is that EC devices, which do not contain nicotine, are safe. The heated liquid of ECs has been shown to result in the release of several carcinogenic substances.[25] These carcinogenic substances are not limited to nicotine only, as studies have shown that vapor of ECs with and without nicotine was cytotoxic and caused DNA strand breaks in keratinocyte and squamous cell cancer cell lines.[26] Thousands of flavors are used with ECs; however, little is known about their toxicity, particularly, after heating and inhalation.[8] In a study that analyzed the air stream of 51 types of flavored EC sold by leading e-cigarette brands and flavors,[27] the investigators reported that diacetyl was detected above the laboratory limit of detection in 77% of the flavors analyzed. The authors concluded that due to the documented associations between diacetyl and bronchiolitis obliterans and other serious respiratory disorders, an urgent work plan is needed to assess the potentially harmful effects of ECs on the lungs and airways.[27] A recent study in youth who smoke ECs reported that excretion of toxic metabolites of acrylonitrile, acrolein, propylene oxide, acrylamide, and crotonaldehyde was significantly higher in ECs users than controls.[28]

Based on the above, although the harmful effects of ECs are probably less than CC, ECs are injurious, and current evidence does not support their use as a smoking-cessation method. The Forum of International Respiratory Societies recently recommended the following:[29]

  1. All electronic devices for nicotine delivery should be considered as tobacco products and regulated accordingly
  2. All modes of promotion of ECs must be regulated
  3. The selling of ECs to youth must be restricted in all nations
  4. The claim that ECs are safe based on comparison with CC, the most lethal product in the history of humanity, is unfair and defective. The proper comparison should be between EC smokers and nonsmokers
  5. All promotions claiming the safety of ECs compared to CC should be stopped
  6. As ECs flavorings enhance the initiation of smoking among youths, these flavorings should not be permitted in all electronic nicotine delivery products
  7. As there is a risk of passive second-hand smoking of ECs vapor, the use of ECs should be banned in indoor locations, public places, and near children and youth
  8. More research is needed to elicit the long-term impact of ECs on different body physiological functions, particularly, their impact on the developing lung and brain.

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