Vaping is an increasingly popular alternative to smoking where a solution is heated below combustion to deliver a cloud of vapor. Since nothing burns, there is little smell and it’s touted and perceived as a healthier alternative to smoking tobacco. However, much of the hype surrounding vaping fails to take into account that while it is similar to smoking tobacco, vaping is a different activity with a different set of risks. E-cigarette users not only inhale vapor—of which there are countless formulations—but also expose themselves to the e-cigarette devices. Some of these contain toxic levels of heavy metals and dangerous chemicals which may be inhaled during use.
The relative newness of vaping means there are few longitudinal studies on its health effects. The variety of e-liquids as well as the many methods and doses in which it is consumed makes the study of the health effects e-cigarette use more difficult than that of tobacco. There has, however, been an alarming study in the Proceedings of the National Academy of Sciences from January of 2018 showing a possible increased risk for cancer and heart disease from DNA damage caused by vaping exposure.
The vaping and e-cigarette market is among the fastest growing in the world, with predictions that it will be worth as much as $65 billion by 2025. Sales are predicted to overtake conventional cigarettes quickly as the latter has reached all-time lows in some markets already. The perceived lack of health consequences may contribute to its popularity, particularly among teens and pre-teens, where adoption has outstripped cigarette smoking by a considerable measure. Critics, however, say this leads to a greater chance of young people becoming addicted to nicotine and turning to cigarettes, which are cheaper.
In this Wild West of e-cigarette entrepreneurship, many small companies are producing niche products and bringing them to market without scrutiny by any regulatory bodies. Health scares have already occurred with incidents of poor ingredient choice creating serious public health hazards. In fact, the nicotine in e-cigarettes could also be a danger, as there is now evidence in mouse trials that it can damage DNA. During the course of the initial mouse trials, researchers found that nicotine vapor inhaled from e-cigarettes seemed to convert to chemicals that damage the lungs, heart, and bladder. It also seemed to affect the DNA, and damage the body’s genetic repair mechanisms, which could indicate long-lasting effects.
What’s in an E-Liquid?
The primary ingredients of most e-liquids are propylene glycol and glycerin. These ingredients are considered safe for human consumption, and purveyors of e-liquids often assume products labeled safe for consumption are also safe to inhale through vaporization. According to the FDA, that is not always the case, as the process of vaporization requires high temperatures that can potentially change some safe products into extremely hazardous ones. There is also a massive difference between ingesting something through the digestive system and putting chemicals directly into the bloodstream via the lining of the lungs, which has pulmonologists concerned.
This common misunderstanding has instilled a false sense of safety among e-liquid creators with some even advertising their e-liquids as food-safe. Some, like Five Pawns in California, are now facing class-action lawsuits for misleading consumers. This marks a turn in the e-cigarette industry. More potential dangers are being recognized every day, and both the World Health Organization and the US surgeon general have released warnings regarding the use of e-cigarettes among young people. One of the most pressing reasons for concern is the sheer number of adulterated products available, including over 7700 unique flavors (as of 2014). There are simply too many e-liquid ingredients used to feasibly test for each one’s dangers when vaporized.
E-cigarette companies are constantly trying new things since there is no real consensus on what an e-liquid should contain. Some vaping enthusiasts have gone so far as to mix their own liquids at home, using completely untested and possibly toxic ingredients, and then swapping recipes online. Due to this trend, which is already apparent from Amazon reviews of some concentrated food flavorings, we can expect to see people vaping a wider variety of products and formulations in the future.
This is happening without oversight; ingredients with extremely negative side effects become popular before their consequences are known, such as has already occurred with the ingredient diacetyl. Diacetyl had been reported to potentially cause bronchiolitis obliterans, also called popcorn lung. Critics contend that there are many other flavorings and chemicals put on popcorn, so diacetyl has not been proven as the sole culprit for popcorn lung. Regardless, the current National Institute of Occupational Safety and Health guidelines limit workplace exposure to diacetyl, and unfortunately, the amount of diacetyl in e-liquids far exceeds these limits. Although diacetyl is now rarely used in most e-liquids because of the controversy, it is still present in some and it is still unregulated.
How Dangerous Could it Be?
Some risks of vaping are already well known. The liquid form of nicotine is skin-permeable, and spills can deliver dangerous amounts of nicotine, a particular worry as more people begin to refill their e-cartridges with their own formulas. Home refills have led to a rise in the use of liquid nicotine, which can be bought in concentrations up to 100 milligrams per milliliter.
Although the lethal dose of nicotine in humans is not known, many estimate that around 10 milligrams per kilogram could be lethal for a child, and 30 to 60 milligrams per kilogram for adults. The lethal dose for dogs has been more thoroughly examined and appears to be 6.5 to 13 mg per kg. By the most generous estimates, spilling one drop of these highly concentrated liquid nicotines could lead to a nasty death.
Some changes in regulation have proven effective already, such as mandating all e-liquids come in child-resistant packaging. This regulation decreased the number of nicotine poisonings in children by 20 percent in 2015. Unfortunately, this was only after it had risen by a frightening 1400 percent from 2012 to 2015; 1.4 percent of those cases required hospitalization due to serious symptoms of nicotine overdose, including seizures, cardiac arrest, respiratory arrest, and coma.
There is also mounting evidence of other, less obvious health hazards that might occur from e-cigarette use. Beyond the toxicity of the chemicals in e-liquids, some vape pens themselves are dangerous. For example, a 2013 PLOS-One study pointed out the potentially toxic content in cartomizer style e-cigarettes. (A cartomizer is a hybrid of a cartridge and an atomizer sold in one inexpensive unit that screws easily onto the battery and holds more e-liquid than older devices with separate cartridges and atomizers.) The researchers found heavy metals and silicate particles present in cartomizer aerosols, revealing the need for improved quality control in e-cigarette design and manufacturing.
As a 2014 New York Times investigation showed, at the origin point of most e-cigarettes—an unregulated China—many vaping devices are made as cheap knockoffs with sloppy manufacturing incorporating dangerous compounds. Inhalation of heavy metals has already been shown to lead to lung cancer. The silicate particles present in cartomizers could also lead to greater instances of silicosis, which is usually only associated with working in hazardous conditions, such as glass factories. Regular exposures of vaping could lead to silicate particles building up in the lungs in the just the same way.
“Dripping” and Vaping at High Temperatures
There are different ways to vape, and there is a new trend toward putting e-liquids straight onto a heating coil to create a stronger hit. This practice, called dripping, contrasts with the slow release of e-liquid onto an atomizer, typical of most e-cigarettes. Dripping exposes users to much higher levels of nicotine and exacerbates the effects of toxic chemicals. Formaldehyde and acetaldehyde, which are known dangerous carcinogens, are also present with dripping.
Dripping is increasingly common among the young. This can be seen in the popularity of videos where people perform elaborate smoke tricks which require dripping. According to a study published in the journal Pediatrics, 64 percent of the teens surveyed said they dripped for thicker smoke, 39 percent did it for better flavor, and another 28 percent like dripping for the stronger throat hit it created, which is more akin to inhaling tobacco smoke.
The nicotine and carcinogens are not the only problems with dripping. The use of much higher temperatures—as high as 450 degrees Fahrenheit, nearly 100 degrees above the usual vaping temperature—is also a health concern. It’s been connected to reports of mouth sores and gum disease, which raise speculation that the lining of the lungs could also be affected.
Many vaping enthusiasts have already begun complaining about open mouth sores that won’t heal and bleeding from the lining of the throat. This is because e-cigarette vapors affect the function of healing cells called fibroblasts. After the fibroblasts were exposed to vapor, they seemed to run out of energy before being able to close the cuts or injuries, according to research by Dr. Irfan Rahman’s team.
Some vape users report coughing up flecks of dried blood, which may come from either the mouth, lining of the throat or the lungs. Higher temperatures have also been linked to creating vapors with carcinogenic carbonyl compounds. The output voltages required for higher temperature vaping was found to significantly affect the levels of carbonyl compounds in e-cigarette vapors in at least one study. This means that high-voltage e-cigarettes may expose users to high levels of carbonyl compounds.
The Dangers for Teens and Pre-teens
Vaping is most popular among young people. In 2016 CDC survey, 3.2 percent of adults reported being regular e-cigarette users, with usage declining steadily with age. Meanwhile, e-cigarette use increased by an astounding 900 percent among high school students between 2011 and 2015. According to data from the 2017 Monitoring the Future (MTF) survey, 13 percent of 8th graders, 24 percent of 10th graders, and 28 percent of 12th graders in US schools had reported using a vaping device or e-cigarette in the prior year. Worryingly, this trend is likely to continue as seven out of ten young people have been exposed to e-cigarette ads, which are not currently banned like the tobacco industry.
Unfortunately, 50 to 75 percent of young people report a preference for the flavored varieties, which we know are among the most toxic. Children are also more likely to start vaping at a younger age relative to smoking (it is legal for those as young as 13 years old to buy nicotine-free vaping products in the UK, for example). There are parents reporting even younger children starting to vape, because of how unregulated the industry is.
Many of the dangers already discussed are of greater concern in the context of a developing body and brain. Heavy metals have direct and known negative effects on the developing brain, including serious learning disabilities. There is also a greater risk for adolescents insofar as they are less likely to be able to afford a vape pen with higher-quality manufacturing.
Even low exposure to the nicotine in e-cigarette vapors can cause problems with brain development, particularly the prefrontal cortex neuronal network function. A 2012 Reproductive Toxicology study that researched the effects of e-cigarettes on embryonic stem cells, mouse neural stem cells, and human pulmonary fibroblasts found that most of the samples tested were cytotoxic, which could impact brain and cell development. The toxicity seemed to correlate with the number and concentration of chemicals used to flavor the e-liquids.
A 2017 report released in the American Journal of Respiratory and Critical Care Medicine asked 2,000 student in their last two years of high school in Los Angeles about their vaping habits. Five hundred students said they had vaped, and 200 said they had vaped within the last 30 days. The more recent vapers were twice as likely to develop symptoms of chronic bronchitis (also known as smoker’s lung) than those who had never tried vaping. Worse still, the students who hadn’t smoked in the last 30 days were “about as likely as current vapers to have chronic bronchitis,” suggesting that the problems persist long after vaping stops.
Children who do not vape still face risks from second-hand vaping. Just like with tobacco smoking, the effects of secondhand exposure is measurable. One small study published in International Journal of Hygiene and Environmental Health found that vaping worsened indoor air quality, leading to higher levels of nicotine and polycyclic aromatic hydrocarbons. There were also higher levels of particulate matter and aluminum compounds which have been linked to cancers, lung and cardiovascular disease, and other concerning health effects. This means it would be prudent for parents and those who like to vape to use the same precautions they would use for secondhand smoke. Some states have already prohibited vaping wherever smoking is banned, including Utah, New Jersey, and North Dakota.
The Real Truth About E-Cigarettes
The assurance that vaping is better for you than smoking has not been substantiated by longitudinal studies. The studies that have emerged paint a very different picture. In 2013, the first compilation and analysis of the health effects reported by e-cigarette users from online forums (in the Journal of Medical Internet Research) showed that e-cigarette users reported wide-ranging effects. A staggering total of 405 different symptoms due to e-cigarette use were reported from three forums. Of these, 78 were positive, 326 were negative, and one was neutral.
Fortunately, regulations of e-cigarettes are growing. Vaping has been completely banned in a number of locations, including Canada, Mexico, most of South America, Turkey, Egypt, and much of Southeast Asia. In the US, Los Angeles has recently followed New York, Boston, and Chicago in restricting the use of e-cigarettes. Both Oregon and Minnesota are also considering restrictions in the near future.
Far from being the risk-free alternative to smoking tobacco, vaping may be just as likely to cause severe health problems, like chronic bronchitis and lung cancer. At the moment, there is little public awareness of these risks; the common understanding is that vaping is at least better than smoking. Yet this has not been proven. We know the associated dangers of smoking and are getting better at treating them every year; the jury is still out about e-cigarettes.