Colourful, attractive holders, flavourful and appealing to young people – this is the transformation of cigarettes to e-cigarettes. Even the name has changed, and they can be sold as electronic inhalers, hookah pens, e-hookahs and vape pens. Flavours range from banana nut, vanilla, chocolate, coconut, lemon, cinnamon, cotton-candy to gummy bear. They are not inexpensive with prices upwards of $20 with refills available for a lower price. Since the flavoured contents are inhaled as a vapor, the process is called vaping.
The change in name is an effort to disassociate e-cigarettes and their namesakes from cigarettes and the known dangers of smoking tobacco. E-cigarettes are designed to deliver nicotine in the form of an aerosol that mimics the smoking experience without real smoke. The name change from smoking to vaping has been very successful. While the battle against smoking has proved relatively successful in promoting information on the dangers of smoking, a new frontier has opened with the rapid advance and marketing of e-cigarettes.
The pros and cons pertaining to e-cigarettes are not all that clear since insufficient data is presently available to determine the health concerns related to e-cigarettes.
- can be used to smoke indoors wherever there are restrictions on tobacco smoking.
- are clearly safer than tobacco for they contain fewer toxins, contaminants and carcinogens. A comparison of contaminants in e-cigarettes found that they did not exceed recognized workplace exposure standards.
- are touted as a method to reduce or quit smoking.
E-cigarette emissions have been analyzed by Goniewicz and colleagues(1) to see if they contained toxic and carcinogenic compounds such as carbonyls, nitrosamines, volatile organic compounds and heavy metals. While they did find toxic substances, the levels were 9 to 450 times lower than in cigarette smoke. Another set of researchers(2) found “substantial amounts” of glycerine, nicotine, 1,2-propanediol and particulate matter PM2.5. When smoked indoors, e-cigarettes increased the indoor levels of carcinogenic polycyclic aromatic hydrocarbons by 20% and more than doubled the levels of aluminum. Further, the nicotine content was 1.2 times higher than claimed by the manufacturer.
Nicotine content in e-cigarettes varies considerably. Some brands that contain nicotine are advertised as being nicotine-free.(3) Concentrations of nicotine can vary from 1 to 24mg/ml. Flouris and colleagues(4) found that short-term use of e-cigarettes resulted in small changes in lung function that were similar to the effect of nicotine in tobacco cigarettes. Nicotine is a highly addictive substance that affects blood vessels, heart rate and blood pressure. The American Heart Association listed the potential health hazards of nicotine including hemodynamic effects, thrombogenesis, endothelial dysfunction, systemic inflammation and other metabolic effects.
Some reported side effects of e-cigarettes include eye, mouth and throat irritation; dizziness, headache, nausea, and coughing.
Propylene glycol and glycerin are major ingredients and their adverse health effects on the person inhaling (vaping) needs further investigation.(5) Propylene glycol can cause respiratory irritation while glycerin is associated with lipoid pneumonia. A study by Williams et al(6) found levels of nickel, chromium and lead in the e-cigarette aerosol that were equal or higher than the levels in cigarette smoke. These metals came from the filament that aerosolizes the nicotine. Some e-cigarettes have been found to contain active pharmaceutical ingredients; prior to a warning by the FDA, they were promoted as a method for weight loss or increased sexual ability.(7)
Many former smokers state that e-cigarettes help reduce smoking and as such they should be viewed favourably. However, Lee and colleagues(8) found that the claim made in an advertisement, that e-cigarettes were a smoking cessation aid, did not hold true in their survey of over 75,000 adolescents. Current frequent smokers were more likely to use e-cigarettes and usage was higher in those who had made an attempt to quit than those who had not. They did not find any adolescents who smoked e-cigarettes who had successful stopped smoking tobacco.
There is concern about these devices that are designed to look less like cigarettes and more like candy, and to appeal to young people. There is a danger that children will be exposed to nicotine through skin contact or consumption of the refill vials. The Morbidity and Mortality Weekly Report of April 4, 20149 reported on the sharp rise in the number of calls involving children and e-cigarettes: from one call in September 2010 to 215 in February 2014, making e-cigarettes a cause for concern.
E-cigarettes sales rose doubled between 2011 and 2012 – from $250 million to $500 million – and are expected to quadruple in 2014.
E-cigarettes are currently unregulated. There are no standards for the level of nicotine, the ingredients, flavourings, labelling or appearance. More research is required to determine their safety and efficacy as an aid to smoking cessation; the long-term effects both on users and individuals around them; and whether on not the neophyte’s use of e-cigarettes will lead over time to use of regular cigarettes.
- Goniewicz ML, Knysak J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014 Mar;23(2):133-9. doi: 10.1136/tobaccocontrol-2012-050859. Abstract.
- Schober W, Szendrei K et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health. 2013 Dec 6. pii: S1438-4639(13)00153-3. doi: 10.1016/j.ijheh.2013.11.003. Abstract.
- Cameron JM, Howell DN, et al. Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions. Tob Control 2014 Jan;23(1):77-8. doi: 10.1136/tobaccocontrol-2012-050604
- Flouris AD, Chorti MS, et al. Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol. 2013 Feb;25(2):91-101. doi: 10.3109/08958378.2012.758197.
- Burstyn I. Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. BMC Public Health. 2014 Jan 9;14(1):18. Abstract.
- Williams M, Villarreal A, et al. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One 2013. 8:3.10.1371/journal.pone.0057987
- Palazzolo DL. Electronic cigarettes and vaping: A new challenge in clinical medicine and public health. A literature review. Front Public Health. 2013 Nov 18;1:56. PMC3859972
- Lee S, Grana RA, Glantz SA. Electronic cigarette use among Korean adolescents: a cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking. J Adolesc Health. 2013 Nov 22. pii: S1054–139X(13)00748-9. doi: 10.1016/j.jadohealth.2013.11.003.
- Chatham-Stephens K, Law R et al. Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014 Morb Mortal Wkly Rep. 2014;63:292–293.