E-cigs are electronic devices meant to turn smoking into a healthier habit by replacing tobacco with a variety of flavorful liquids. The dangers of smoking as suggested by a plethora of research projects do not seem to make people worry as much as they should.

Smoking has always had a recreational purpose, and its harmful effects quickly fell to a second place. Not even the fact that it often time causes addiction raised question marks over how damaging it might be for our bodies. However, an increasing number of medical experts are willing to show people to what extent smoking can alter their health.

Studies show that nicotine, one of tobacco’s main compounds, affects homeostasis and impedes the immune system’s buying functioning. Moreover, frequent cigarette use encourages cell damage in vital organs such as lungs, heart or brain. Toxicological reports link nicotine exposure to an increased risk of cancer. Quitting smoking might be a challenge in the beginning and addiction is often hard to overpass. As time goes by, it becomes a serious issue because persisting in this habit might mean prioritizing other factors in front of life. Fewer cigarettes smoked or the use of electronic devices could be the answer for those among us that find it hard to quit smoking.

E-cigarettes: The Truth Behind the Public Opinion

An electronic cigarette, also known as a vaping device, is a handheld electronic designed to vaporize a flavored liquid containing various compounds instead of the regular tobacco burning. The liquid found inside the e-cigarette contains a mix of nicotine, glycerin, propylene glycol and other flavors that often offer a pleasant aroma. Most of the times, they are designed to resemble traditional tobacco cigarettes. Newly produced devices imitate everyday items such as pens or USB memory sticks. About 250 brands are active at the present moment.

Ever since their entering the market in 2004, they have enjoyed a good renown thanks to the tens of millions of users all over the globe. People have confessed to buying e-cigarettes in spite of uncertain safety status.

In 2016, the FDA specialists decided to extend their authority to include electronic cigarettes and other known tobacco products. Regardless of the fact that this may increase people’s confidence when buying them, e-cigarettes should not be considered harmless. While less toxic than a conventional cigarette from numerous points of view, there is enough evidence on e-cigarettes’ side effects [1] and possible health-related risks to raise concern.

The electronic devices are known for creating an aerosol called vapor that imitates the tobacco cigarette smoke. The vapor’s compounds differ from one manufacturer to another but the basic ingredients are the same. Studies conducted on their structure showed that e-cigarettes could contain toxins and even traces of heavy metals due to the interaction of the device’s metal part with the e-liquid. The toxic elements are present at permissible levels by various associations. Likewise, certain chemicals with potential risks are found in their composition low-quality, but the concentrations are not high enough as to raise questions. Later generation e-cigarettes may produce high levels of methanol, a volatile organic compound regarded as a possible cancer agent.

Some items have nicotine-based formulas that in vitro studies deem as carcinogens. Truly worrying is that many people who choose to replace the usual cigarette with an e-cig rarely find the time to document on the disadvantages such a decision implies.

Mechanism of Action

An electronic e-cigarette is composed of six main parts: a mouthpiece, a tank, heating elements, a battery, a microprocessor and a LED light (not all devices have this part). The cartridge holds a liquid solution comprised of nicotine (in some cases), flavorings and other chemicals. The small heating element inside the atomizer is activated by either punching a button or through a pressure sensor that reacts to air inhalation. The liquid reaches a temperature that ranges between 212 to 482 degrees Fahrenheit in a matter of moments. The vapor also named aerosol, is inhaled by the user, offering one the satisfaction of smoking without being exposed to the dangers implied by tobacco exposure. The typical e-liquid is made of propylene glycol and glycerin in a proportion of 95%. The majority of electronic cigarettes have lithium batteries that are linked to the occurrence of accidents[2] due to their relatively low-quality standards. Various people have suffered injuries because the batteries exploded and the device caught fire.

E-cigarette explosions[3] are not rare. Many of them followed in facial injuries, teeth loss, eye problems and skin burns shortly after the battery acid made contact. According to data from the U.S. Fire Administration, twenty-five of the fires that took place between 2009 and 2014 were caused by e-cigarette explosions.

Later generation devices seem to have better quality batteries mainly because the new models contain liquids richer in nicotine than the first generation e-cigarettes. Stronger batteries are required to heat the solution and make the device functional.

A Global Trend

Ever since the Chinese pharmacist Hon Lik first invented the e-cigarette in 2003, the product has enjoyed increasing popularity[4]. Today, the majority of e-cigarettes are produced by Chinese manufacturers. The main consumers are young people and adults who try to quit smoking. Electronic cigarette companies sell their products in retail stores as well as online, with the latter being the favorite option of many over the years.

There are three popular types, namely the cigalikes, eGos, and mods. They differ in regards to their aspect, but the mechanism of action is roughly the same. Some of them look like tobacco cigarettes while others imitate the appearance of pipes, pens and memory sticks. Individual components such as the cartridge or e-liquids can be bought separately in accordance to one’s taste. Consumers regard them as more practical than tobacco cigarettes[5] as they last for longer, and the tank does not need to be refilled too often. A cartridge can last as long as twenty tobacco cigarettes which make it appealing to customers with tighter budgets. The FDA, as well as the European Parliament, extended their regulatory influence to include e-cigarettes in spite of presumed risks. No less than 466 e-cigarette brands were registered as of 2014. The brands recorded global sales of about seven billion dollars that year.

Electronic cigarettes are currently used by about 8% of the American population.

Consumers are predominately men, although the device seems to be well-known by women as well. They are notorious among young people, with 13% of the American high school students confessing to own an electronic cigarette. Studies show that teenagers who have such a device are more prone to become smokers than those who do not. Most of them affirm to have tried them for the first time out of curiosity.

Electronic cigarettes may deliver any other compounds other than nicotine and the usual flavors as the cartridge functions for as long as it contains a liquid such as THC or CBD oil juice. Some cannabis smokers find them practical as they are more discreet when used in public. There are no known health risks to the use of cannabinoid-enriched e-liquids.

Are Electronic Cigarettes Safe?

Present-day research does not provide e-cigarette consumers with enough information about the device’s higher safety degree when compared to usual tobacco cigarettes. Thus, their status as better alternatives to regular smoking is uncertain. In 2014, the WHO experts stated that e-cigarettes have potential health-related risks, albeit minor, when compared to tobacco cigarettes. Not once have researchers found mismatches between the nicotine concentration found in some devices and the information on the label. On top of that, not all those claimed to be “nicotine-free” are indeed so. People’s confidence in manufacturers could drop considerably due to these factors. Studies conducted on e-cigarettes’ structure and chemical composition show significantly different results. In addition, certain carcinogenic compounds present in tobacco were found in some e-liquids as well. Diethylene glycol, a poisonous solvent, is one of them.

Reviews on electronic cigarettes’ side effects show no severe damage aside from vomiting, nausea or throat, and mouth irritation. Due to reduced toxicity levels[6] compared to those of tobacco cigarettes, they lead to the named adverse effects only when excessively used.

Concern exists in regards to the possibility of accidents with some people misusing them. In other cases, the lithium-based batteries are of poor quality and can increase the occurrence of explosions, be they minor or major. The e-liquid is generally regarded as safe. The fact that it has certain toxicity is not influenced by its formula but rather the frequent contact with the metal constituents of the e-cigarette.

Using them on a regular basis may generate formaldehyde, although in small amounts. A 2015 review shows that later generation e-cigarettes can produce the harmful agent in similar quantities to those found in usual cigarettes. People who buy e-cigarettes that contain nicotine may experience some of nicotine’s side effects.

Few studies indicate tobacco’s role in cancer cell growth but they were demonstrated only in vitro and not in vivo studies. There is not enough scientific proof to link nicotine to the risk of cancer.

The e-liquid contains various chemicals from nicotine to flavors and even small amounts of toxicants. Propylene glycol and glycerin are the two main constituents. Each compound is present in certain quantities which may vary from one manufacturer to another. All compounds were tested and deemed as safe to use. Nonetheless, American Cancer Society experts state that the substance’s safety status is legal only when the constituents are ingested. Specialists claim there are differences between the way the human body reacts to ingestion and inhalation. While they might not be damaging to the stomach, the lungs are more sensitive to the e-cigarettes’ vapor, especially when one vapes on a regular basis.

The e-liquid does not raise concern for the moment due to a lack of data on its side effects.

Another issue is that people have this misconception that electronic cigarettes are healthier alternatives to tobacco cigarettes which is not exactly true.

Specialists in health and care state there is no evidence that e-cigarettes are entirely safe to use. People usually assume that the device is good for them as it contains little to no nicotine but overlook the other constituents. There are products on the market that have been tested for their effectiveness and play an active part in nicotine replacement therapies, namely the nicotine patch and nicotine gum. Unlike them, e-cigarettes have no studies conducted on their potential role in this type of treatment. The compounds found in electronic cigarettes are similar in toxicity to other nicotine-based products. Even so, due to their physical components and the way they interact with each other, people have few reasons to consider them harmless.

What Are the Risks and Side Effects?

Health organizations have shared opinions on the subject of electronic cigarettes’ safety. Various medical associations together with the FDA are unsure whether to deem them as safe for general use. Nevertheless, public opinion appears to contradict their statements. For most customers, an e-cigarette is a way of enjoying smoking that is pleasant and healthier at the same time. There is limited data on the device’s adverse effects if used for extended periods. Likewise, specialists do not recommend them in treatments for people who try to quit smoking as there is insufficient proof of their effectiveness. Moreover, there is an increased concern since many teenagers own such products. Most of them do so as a mean to look cool or fit in. Surveys indicate that adolescents who buy non-nicotine e-cigarettes in the beginning but resort to the nicotine ones soon afterward are more prone to start smoking tobacco cigarettes. Still, a report made public by the California Department of Public Health[7] showed a decrease in the number of adolescents who smoked after they started using electronic cigarettes.

The FDA Center for Tobacco Products made public forty-seven cases of people who suffered from side effects due to the use of electronic cigarettes. Eight of them were severe, while the rest were associated with less serious damage. Other cases have been reported in Spain and the UK However, there is no clear evidence that they are the main reason behind the accidents. Medical specialists affirm that most, if not all situations, were the result of already existing health problems and the electronic cigarettes may have been the triggering factor.

The following are some of the issues associated with the use of e-cigarettes. Specialists may consider conducting more studies both on the device’s side effects and benefits as the existing information is either unclear or insufficient.

E-liquid Related Issues

The liquid found in electronic cigarettes is quickly absorbed by the skin following contact. People can be exposed to nicotine or other toxic compounds as a result. Aside from containing nicotine, glycerin or propylene glycol, e-liquids are rich in flavors. There are about 8000 flavors at the present moment. Many of them bear suggestive names such as “tutti frutti gumballs” or “My birthday cake”. This, combined with their intricate and appealing containers, may present curiosity for children. Many kids usually try new things by either touching or tasting them so they may be tempted to explore an e-cigarette also. In addition, the device’s tank is not hard to open so children can easily reach for the bottles of liquid, break them and ingest the substance. E-cigarettes that contain nicotine are even more dangerous as only six milligrams of nicotine are lethal to a small child. Therefore, it is advisable to store the electronic devices in a place where children cannot reach for it. Whereas accidents can take place at any time, more resistant opening systems might constitute the answer for the concern generated by some improperly made devices.

Pregnant and nursing women should avoid e-cigarettes, be they nicotine or non-nicotine.

Media sources have reported cases of people that attempted suicide by swallowing or injecting the e-liquid. Three deaths were confirmed and all of them implied nicotine e-cigarettes.

Poisoning Due to Ingestion or Inhalation

The nicotine concentration, be it in tobacco cigarettes or the electronic ones, is not associated with the amount of nicotine that reaches the bloodstream. Most situations involving poisoning due to e-cigarette use had a common element: the presence of nicotine in the e-liquid’s composition.

Four adults and two children died after ingesting liquid nicotine. Calls to the United States poison centers involved poisoning because of inhalation, ingestion, skin or eye exposure to nicotine. People reported a wide range of symptoms, which varied in intensity. Some of the accidents’ side effects included nausea, chest pain, headaches, eye irritation, hypertension or hypotension. The majority of cases implied children[8]. The number of calls to U.S. poison control centers increased between 2010 and 2014. The statistics registered a decrease in 2015. Some U.S. states have imposed newer standards[9] regarding packaging of e-liquid containers after an 18-month old baby died shortly after ingesting 100 milligrams of liquid containing nicotine. Another 15-month old girl tragically died after mistaking the liquid for medication. The autopsy showed that death occurred as a result of severe anoxic brain injury (lack of oxygen) due to a high nicotine concentration in the blood.

A 2015 study[10] showed that both the flavored liquid and the vapors produced by an e-cigarette are directly linked to a weaker immune system response to oxidative stress and toxic agents. Exposure of lung epithelial cell to e-cigarette smoke led to an increase in inflammatory leukocyte levels. The toxic emanation might be related to the pathogenesis of lung cancer.

Battery-Related Incidents

Most e-cigarettes use lithium batteries that are not exactly a standard among other batteries types. Some batteries are made of poor quality constituents while others have defects. The majority of cases that involved explosions of electronic cigarettes were due to improperly designed batteries. The U.S. Fire Administration stated that twenty-five fires and explosion were caused by electronic cigarettes between 2009 and 2014. Many patients presented to the ER department with either partial or full-thickness burns[11].

The cigarettes usually exploded in a pocket pant, but there were a few cases reporting facial injuries as well. Two U.S. patients needed surgery to reconstruct the injured part. Little is known as to why the instantly combust in spite of looking alright at the time of the purchase. Negligence due to mass production might be one of the reasons. Overheating as a result of inappropriate voltage/battery resistance capacity ratio could be another.

Nicotine Replacement Therapy (NRT)

Smoking can be either a matter of personal choice or environmental influence. Usually, people start using tobacco as a means to relax in their adolescence when many of us are more likely to imitate what we see in others. However, what is in the beginning just a way of spending our free time could become a lifelong addiction we can hardly escape. Whereas experts state that cigarette use is a major cause of death, they also tell us that it’s easily preventable. Additionally, people who want to quit smoking benefit from help from many parts whether we talk about psychologists, treatment centers or products designed to reduce the need for nicotine

In Nicotine Replacement Therapy, patients are advised to use alternative nicotine sources as to facilitate the transition from smoker to non-smoker. They can choose one or more of the following: nicotine gums, nasal sprays, inhalers, transdermal patch or sublingual tablets. Nicotine vaccine or pulmonary inhalers are newer and possibly the more effective methods employed nowadays. According to a population-based study[12] conducted on more than 50.000 patients, people following NRT were more likely to quit smoking than those who were not involved in this kind of therapy. The products’ effectiveness was shown to be independent of the participants’ will. As of late, the involvement of electronic cigarettes as an active part of the smoking cessation process has been attempted. There is data pointing towards success in nicotine replacement therapy of e-cigarettes[13], but it is too poorly presented as to exhibit interests to consumers and researchers alike. In one clinical trial[14], nine men and two women were asked questions regarding their opinion on the device and why it would work better than other products included in NRT. Five main factors were noticed once the study was concluded:

  • Bio-behavioral feedback (vaping offered them similar sensations to smoking a real cigarette in that they were able to inhale something, and were visually satisfied by the smoke coming out of the device)
  • Distinction between smoking cessation and nicotine cessation (it appears that smokers are addicted to nicotine more than to the act of puffing from a cigarette; some of those that took part to the study have confessed that e-cigarettes give them the impression they can turn smoking into a healthier activity)
  • Smoking as a hobby (the different flavors in e-liquids turned vaping into something pleasant, and triggered their interests on what an e-cigarette flavor contains)
  • Personal identity (in time, a habit becomes part of one’s manner of being as stated by one participant)
  • Social benefits (vaping, just as smoking, strengthened the feeling of belonging to a  community and sharing similar points of view with all sorts of individuals)

However, results from such studies might have little relevance for the scientific world. E-cigarettes’ efficacy[15] should be based on the chemical reactions that take place inside the body and which can trigger the desire to quit smoking. Moreover, one should not overlook the uncertain safety status of e-liquids that may contain toxic compounds.

E-cigarette Use as a Means to Quit Smoking

There is insufficient information on how efficient an electronic cigarette really is in people willing to become tobacco-free. Specialists do not have confidence in this kind of devices to integrate them into Nicotine replacement therapies as they did with the nicotine gum or patches. This might be either due to insufficient research or distrust in their quality. Harmful effects[16], although minor, are likely to occur at some point. The fact that new products appear every day leads to an increase in the number of e-liquid flavors. This only increases the number of compounds with no studies conducted on their chemical composition, some of which might be carcinogenic.

There are mixed opinions on this subject as well. On the one hand, people are claiming that there could be at least one such harmful constituent in e-liquid’s formula, but the low concentration is unlikely to affect the consumer’s health. On the other hand, others think that frequent exposure to cancer agents is just as bad, whether we talk about those found in e-cigarettes or tobacco ones. In spite of all these, electronic cigarettes increase in popularity by the year. Most smokers regard it as generally less harmful than smoking tobacco although only a small part of them wants to get informed about the benefits/ side effects ratio.

After their entering the U.S. market in 2007, they were sold predominantly online until some years ago. This meant lower visibility in the sight of the FDA, thus no need for them to be regulated. Generally speaking, no regulation means little to no research regarding a specific product. For this reason, the first manufacturers had the freedom to integrate nicotine in the e-liquids without making the information public. There are high chances that some of today’s producers might do the same although to a drastically lower extent.

Because of this, e-cigarettes are unlikely to be helpful[17] in the process of quitting smoking. Currently, the FDA does not approve the use of electronic devices as part of replacement therapies due to their uncertain composition. Additionally, as some devices might contain a considerable nicotine amount, there are low chances people could escape addiction by using them. That is why some e-cigarette smokers continue to use tobacco every once in a while. Realizing that such a simple act can lead to disease, resorting to electronic devices could be just a minor step in the whole process. However, as difficult as it might appear, overcoming addiction is not something impossible to achieve. We need to invest time and dedication to living a healthy life. There are always specialists willing to give us a helping hand and make it easier for us to reach our goal. In spite of people’s approval, electronic cigarettes provide us with only the illusion that we are on the right path. Effectiveness in their case is highly unlikely in comparison to products already included in smoking cessation therapies.

Final Assessment

Electronic cigarettes are devices meant to provide the user with the pleasure of smoking without the most of the toxic compounds released by smoking tobacco. Little was known about their mechanism of action and e-liquid composition until a few years ago when sales skyrocketed. Nowadays, vaping appears to be less of a trend and more of a normal thing people do whenever they want to enjoy some minutes of relaxation. As they did with so many products before, experts have tried offering e-cigarettes a secondary purpose by integrating them into nicotine replacement therapies. Success rate, although existent, is currently low. While they might help people smoke less and vape instead, surveys assert that the majority of e-cigarette customers stick to the old practice of smoking in spite of vaping rather often.

Development in their appearance and manner of action might raise interest among people who want to cease tobacco consumption but tend to avoid other NRT. Additional studies are required as to determine once and for all the side effects of long-term vaping. Pieces of information point towards contradictory conclusions, with only a few of them inclining towards positive aspects. However, the risks and dangers of e-cigarettes remain overshadowed by strong and possibly baseless confidence in their safety status.

Photo Credit[18]

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