This article was written by Bernard Garbe Chairman, Vitalograph. It originally appeared in OH today – the official magazine of the iOH, Volume 26 Number 4 in July-August 2019. Link to original article here: https://ioh.life/wp-content/uploads/2019/09/OH-Today-July-August-2019-1.pdf
E-cigarettes are used as an alternative to cigarette smoking and as a type of nicotine replacement therapy, with suggestions that they are markedly less harmful than cigarettes to the user. There is confusion around the safety of e-cigarettes which stems from contradictory findings due to variations in experimental methodology in the testing of different devices which has not been accounted for. The harms associated with the use of e-cigarettes are not well understood and this is commonly misconceived as meaning that they are a healthy alternative to smoking. This misconception is further exacerbated by physicians and public health bodies which have made recommendations without strong scientific evidencei. But the real concern is the epidemic of teenagers and young adults now starting to vape or smoke E-cigarettes because they consider them ‘safe’ii.
Breaking news: The FDA clamps down electronic cigarette manufacturers
In July 2019, a US federal court decision announced that e-cigarette manufacturers must submit their products to the FDAiii. This was the result of medical and public health groups suing the Food and Drug Administration for the agency’s failure to start the regulation of e-cigarettes. Under the court order e-cigarette manufacturers have until May 12, 2020 to submit their products for review by the FDA. Manufacturers that fail to meet the product application deadline will be subject to removal from the market by the FDA. The FDA has 12 months to review and decide on product applications. This process also applies to a new generation of sweet flavoured cigars recently placed on the market. The judge noted that the Industry has raised every roadblock it can and has taken every available delaying measure to keep its products on the market without approval. The situation is the same in the UK, hopefully we will soon catch up and pass similar legislation.What is an electronic cigarette?
Electronic nicotine delivery systems are commonly known as e-cigarettes. E-cigarettes are relatively new products that deliver nicotine through a liquid (e-liquid) consisting of glycerine and/or propylene glycol, as well as sweet flavourings very attractive to young people. The basic components of an e-cigarette are a cartridge containing a nicotine solution, a heating element that aerosolizes the solution, and a power source for the heating element, which is usually a rechargeable lithium battery.
E-cigarettes are reputed to emit fewer and less dense toxicants than combustible tobacco products. However, some deliver higher levels of nicotine and formaldehyde than conventional cigarettes. They can be purchased in several concentrations of nicotine, ranging from 0% to 36%iv. E-cigarette aerosol is not harmless “water vapour”, it pollutes clean air.
E-cigarettes do not contain tobacco, but most contain nicotine and other harmful chemicals found in conventional cigarettes. The process of heating the nicotine solution to produce the aerosol also produces aldehyde, acetaldehyde, and acrolein (the simplest unsaturated aldehyde), all are known carcinogens. The glycerine/propylene glycol and 8,000+ flavourings in E-cigarettes are found in many food products and are generally considered safe for human consumption. However, safety for these substances was established for eating them, not for aerosolizing and inhaling them into the lungs.Vaping and smoking in pregnancy
There is no known safe level of nicotine exposure to the developing foetus, and exposure during childhood is not recommendedv. Nicotine delivered by E-cigarettes during pregnancy could result in multiple adverse health consequences for normal child growth and development, including sudden infant death syndrome, altered brain corpus callosum, obesity, deficits in auditory processing causing delayed speech, deficits in attention and cognition, and various eating disorders.Nicotine free options
Discussions around e-cigarettes and other vaping devices tend to focus on nicotine, which is highly addictive and carries other health risks, but there are nicotine-free vaping products. Many users believe that if they stick to these products, they would only be inhaling harmless water vapour. The truth is, the other chemicals found in e-cigarette liquid, flavourings and aerosols are not safe.
A recent studyvii evaluated 40 e-cigarette refill liquids and found toxic levels regardless of nicotine content. The toxicity seemed to be associated with the number and concentration of chemicals used in the flavouring. Though the toxicity of e-liquids varied depending on brand and flavour, this and a number of other studies found that cinnamon flavoured e-cigarettes have the greatest potential health riskvi.
Regardless of nicotine levels, there is good reason to be concerned about the effects of the toxic chemicals found in e-cigarettes. With or without nicotine, the evidence to date suggests that e-cigarettes and other vaping devices are not risk free.Toxic chemicals
A large number of chemicals used in e-cigarettes and vaping products have serious health consequences, including cancer, lung disease, and heart disease. A recent studyviii found five cancer-causing toxins in the urine of 16-year-olds who inhaled e-cigarette vapour. If they also smoked cigarettes, the levels were even higher. Another study found that some e-cigarettes release formaldehyde, a possible carcinogen, when heated and inhaled. Another example is diacetyl, a chemical added to food to produce a buttery taste and is harmless when ingested this way. But when heated up and then inhaled, diacetyl has been linked to a respiratory disease called bronchiolitis obliterans, which is also known as “popcorn lung,” which first appeared in workers who inhaled artificial butter flavour in microwave popcorn processing facilities.
Many E-liquids are custom-mixed by individuals at home without any safety regulations, leading to the potential for additional health risks. Many commercial E-liquids are produced with unknown contents, manufacturing procedures, packaging materials, and purity standards.
E-cigarettes are a source of extremely high doses of ultrafine particles in the human respiratory system. These particles have been linked to cardiovascular disease in smokers, and early evidence suggests that the same biologic mechanism may apply to E-cigarette vapour. Of greater concern are the 8,000+ added unique flavourings that are considered safe for use in food but have not been widely tested for their potential sensitising, toxic, or irritating characteristics.Young people consider e-cigarettes safe
E-cigarette usage has drastically increased in the past 5 years due to age restrictions on conventional cigarettes, aggressive marketing and a perception that e-cigarettes are a healthy alternative. E-cigarettes contain nicotine, water, glycerol, propylene glycol and a huge range of flavourings. On inhalation, the device heats the ingredients into a vapour. While tobacco cigarette smoke is known to cause deleterious effects on the cardiovascular system, angiogenesis and skin capillary perfusion by causing direct injury to blood vessel walls, increased platelet aggregation, microvascular thrombosis and inflammation, the consequences of e-cigarette vapour exposure on the lung are still largely unexplored.Epidemic caused by addiction
Research clearly shows that nicotine exposure during adolescence can quickly escalate into nicotine addiction. The younger the exposure to nicotine, the stronger the influence on the developing brain. Pre-teen exposure is associated with stronger nicotine addiction, impulse control problems and disruptive behaviours, and early engagement with other substances such as alcohol, marijuana, and other drug use. What typically begins as youthful experimentation can easily lead to a lifetime of nicotine addiction and possibly drug abuseix.E-cigarettes as an aid to smoking cessation
There is not enough scientific evidence to support that e-cigarettes are an aid to smoking cessation due to a lack of controlled trials. This includes trials that compare e-cigarettes with licensed stop-smoking treatments, of which there have been a few, but not enough.
Many adults are using e-cigarettes in an attempt to quit smokingx. However, most adult e-cigarette users do not stop smoking cigarettes and are instead continuing to use both products (known as “dual use”). Similarly, there is some but insufficient evidence of e-cigarettes normalising smoking behaviour leading on to smoking tobacco products, the so-called gateway hypothesis.
In cell cultures and animal studies it has been shown that e-cigarettes can have multiple negative effects. The long-term effects of use are unknown, and there is therefore no evidence that e-cigarettes are safer than tobacco in the long term. Negative health effects cannot be ruled out, based on our current knowledge.Smoking cessation aids
Whether the smoker uses tobacco, marijuana, e-cigarette or a combination, all have a negative health effects and the worker should be encouraged to give up. For many this is extremely difficult but there are a variety of well proven methods to assist the occupational health professional in providing the motivation and support.
I have given many talks to people interested in giving up smoking. A great demonstration is a home-made smoking doll (but very messy – do this outdoors). The doll’s ‘lung’ is a small plastic bag which the smoke and particles from the cigarette pass through. The result at the end is a discoloured sticky mess in the bag – very impressive, this from just one ‘smoke’.
E-cigarettes do not have carbon monoxide in their smoke, but tobacco cigarettes do. The BreathCO used before and during the smoking intervention is a great motivator, demonstrating (with a knowledgeable and enthusiastic presenter) the huge difference in before and after CO levels in the blood and the damaging consequences of carrying this poison in the body long-term.
Another motivational opportunity arises during routine spirometry or even with a simple device like the Vitalograph copd-6. The worker presenting with a reduced FEV1 may shrug it off, but if presented with information that they have the lungs of a much older person they tend to take notice and may even be offended. Managed properly this could motivate them to quit smoking or vaping.Clinical Trials
Vitalograph is heavily engaged in clinical trials in several different areas. Our medical devices and specialist multinational clinical studies services include the investigation of many new treatments, pollutants and devices. In the EU at present 34 of the published protocols mention electronic cigarettes, most are COPD medicine studies which involve UK researchers. Globally there are 269 multi-national studies mentioning e-cigarettes, mostly based in the USA.Health effects of electronic cigarettes, vaping and lung cancer
Electronic cigarettes put nicotine into the lung and from there into your bloodstream. They do it without the smoke and tar of a normal cigarette, but other harmful things can get into your body when you vape. That is especially true if you use flavoured cigarettes. E-cigarettes heat up the nicotine, flavourings, and other chemicals to turn them into a vapour that you can breathe in. Many chemicals that cause cancer are in this vapour, including formaldehyde, heavy metals, and tiny particles that can get trapped in the deepest parts of your lungs, the alveoli.
But some studies show that high-voltage e-cigarettes have more formaldehyde and other toxins than standard e-cigarettes. Also, some chemicals in e-cigarettes can irritate the airways in your lungs. This can cause problems. Studies have found that flavourings like cinnamon can cause inflammation of cells in the lung. But more research is needed to understand the long-term health risks of vaping.Popcorn Lung
One chemical in some e-cigarette additives is a buttery-flavoured one called diacetyl. It has been linked to a serious lung disease called bronchiolitis obliterans. It's also known as popcorn lung. In fact, the condition was first identified among popcorn factory workers who inhaled the chemical in the workplace. Popcorn lung is a rare condition that causes airway scarring due to inflammation and eventually lung damage. While treatments exist to limit and manage symptoms, currently there is no cure for popcorn lung, and it is considered life-threatening. Over time, inflammation associated with popcorn lung causes lung tissues and airways to scar and narrow, causing breathing difficulties.E-cigarettes and COPD
The first evidence linking e-cigarette use with new cases of chronic obstructive pulmonary disease (COPD) was presented at the American Thoracic Society meeting in May 2018xi. COPD can take decades to become evident but this study found a strong link between e-cigarette use and COPD in a longitudinal study. E-cigarette users were about twice as likely to have COPD.
E-cigarettes have been shown to induce greater inflammatory mediators from COPD lung cells. Therefore the risks of e-cigarette use in COPD might be greater than in people without COPD. Multiple studies have concluded that e-cigarette vapour exposure could lead to inflammation, emphysema and a greater risk of bacterial and viral infection.COPD Guidelines and spirometry
In the workplace healthcare surveillance is important to detect the onset of a work-related exposure causing harm long before serious and permanent damage is caused. Equally lifestyle behaviour unrelated to the workplace, such as vaping or smoking, may be causing damage to health especially if this damage is insidious. Lung disease is often like this, it can take decades before the worker is aware of a problem.
But routine annual spirometry with serial trending will show the presence of a faster than normal decline in lung function long before the worker becomes aware of a problem. The COPD guidelinesxii recognise tobacco smoke as the primary cause of COPD. Soon this will incorporate the inhalation of fine particles and toxins from e-cigarettes.E-cigarette users more susceptible to heart, cancer and influenza, especially in women
A cross-sectional analysis of studies has shown that daily e-cigarette users are about twice as likely to have had a heart attack compared to a non-smoker.xiii
Evidence suggests that, despite delivering lower levels of carcinogens, e-cigarettes could be increasing the risk of lung cancer.
E-cigarettes affect the body’s response to viral infection, but the effect of using e-cigarettes is different for females and males, and it’s different from the effect of smoking regular cigarettes, according to new researchxiv. This preliminary research investigating differences in immune response between non-smokers and people who use cigarettes or e-cigarettes was presented at the 2019 American Thoracic Society (ATS) International Conference in Dallas, TX. The immune response in female e-cigarette users was “suggestive of immunosuppression” while in males it was “a mixture of immune gene upregulation and down regulation.” Any impairment of immune responses to pathogens has the potential to increase susceptibility to infection or vaccines, suggesting that e-cigarette users, especially female e-cigarette users, may experience increased risk of infection.Second-hand inhalation effects
Second-hand exposures to E-cigarette chemicals may represent a potential risk, especially to vulnerable populations, just as tobacco smoke doesxv. E-cigarettes and vaping are too new and insufficiently regulated at present for proper studies to be conducted, but anecdotal evidence is clear.
I am an asthmatic and I immediately feel tightening of the chest when I encounter tobacco smoke, or indeed a ‘vaping trail’. I am constantly assaulted by people smoking and vaping in doorways and walking in the street. I go out of my way to avoid these inconsiderate people as well as holding my breath. It’s not just me. Second hand smoke causes stroke, lung cancer, and coronary heart disease in adults. Children who are exposed to second hand smoke are at increased risk for sudden infant death syndrome, acute respiratory infections, middle ear disease, more severe asthma, respiratory symptoms, and slowed lung growth.Public Health England
Public Health England (PHE) has published a framework advice for businesses and employers to help them create their own policies on the use of e-cigarettesxvi. There are now 2.8 million e-cigarette users in the UK and there is a need for appropriate policies in public places and workplaces. PHE’s new framework helps organisations create e-cigarette policies that will support smokers to quit and stay smoke free, while managing any risks specific to their setting.
The framework acknowledges that workplace environments vary greatly and there is no one-size-fits-all approach; a factory or warehouse is a very different setting to a nursery school, with different considerations to make. It sets out 5 important principles for an approach based on our current knowledge of e-cigarettes.Conclusion
Employers should treat E-cigarettes and vaping like tobacco smoking. Don’t allow E-cigarettes in the workplace or outside entrances, but only in the designated smoking area.
E-cigarettes are relatively new and the research on their effects, especially the potential long-term effects, is limited. Vaping products usually contain nicotine, a highly addictive drug, although they do not involve tobacco smoke inhalation. Some vaping products may also contain:
- cancer-causing substances or carcinogens
- toxic chemicals
- toxic metal nanoparticles
The growing evidence suggests that vaping is less harmful than smoking conventional cigarettes. But the healthcare professionals advise against e-cigarette use by young people, those who are pregnant, or adults who do not currently use tobacco.
Some Video Resources:
- http://bit.ly/1UT2Wv6 Are E-cigarettes Harmful? (Time: 1½ mins)
- https://youtu.be/S3IgZ2-rSgs US Surgeon General talks about health and E-cigarettes. (Time: 27 mins)
- http://bit.ly/1KXJIhk E-cigarettes from a public health perspective. (Time: 41 mins)
iMcNeill A, Brose L, Calder R, et al. E-cigarettes: an evidence update. A report commissioned by Public
Health England. London, Public Health England, 2015.
iiQuick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults.
iiiATS Celebrates Court-Established Deadlines for E-cigarettes and Cigars Regulation.
ivVaping/Electronic Nicotine Delivery Systems
v About Electronic Cigarettes CDC:
vi MYTHS: Are Nicotine-Free E-Cigarettes Harmful?
vii Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models
viiiAdolescent Exposure to Toxic Volatile Organic Chemicals From E-Cigarettes
ix Nicotine and the adolescent brain. Journal of Physiology 2015;593(16):3397–3412.
xQuit Methods Used by US Adult Cigarette Smokers.
xiFirst evidence linking e-cigs to COPD in the population
xii Global Initiative for Chronic Lung Disease GOLD
xiii Smoking E-Cigarettes Daily Doubles Risk of Heart Attacks
xivE-cigarette use disrupts normal immune response to viral infections, in women particularly
xvi Use of e-cigarettes in public places and workplaces