*Names have been changed to protect the privacy of the interviewees.
The last time Moses saw his son Thaddeus, his pride and joy was paying the price of half a lifetime of smoking. He was brought to the ER because he had difficulty breathing one afternoon, and doctors worked frantically to restore oxygen to his lungs. Prior to this, he had been so healthy that apart from his birth, he had never visited a hospital as a patient. The next morning, having just turned 40 the previous month, Thaddeus was dead. His sister Martha ﬂew in from Canada, hoping to catch him at the hospital and see him recover. Instead, she was picked up from the airport and brought straight to the funeral home.
Thaddeus came out as a traditional cigarette smoker in his 20s when it was ‘safe to do so’. But his family always suspected that he started smoking in his teens. He just hid it from them because he attended an international school for expats in the Middle East, where they have strict rules against consumption of addictive substances, including nicotine. When their family moved to a country where he could publicly smoke to his heart’s content, he had successfully transitioned from being a chain smoker to a regular one.
When the electronic cigarette became a trend, he switched, hoping to kick the nicotine habit for good. Little did he know his puffs from the popular device were going to be his last. He was vaping when he asked his dad to bring him to the hospital. Moses relayed this information to the ER doctors.
Martha couldn’t accept pneumonia as the cause of her brother’s untimely death, especially after she learned that their father had seen his room littered with vials of fruit-scented e-liquid. So she demanded an autopsy despite the hospital oﬀering to waive all medical fees if she didn’t go through with it. But relatives pressured her to accept the oﬀer to save their father more grief.
This senseless passing is just one example of parents losing their children to some form of addiction. Of course, we mortals don’t have control over our expiration dates, but we could take steps to delay them. Deaths like Thaddeus’s could have been prevented with intervention.
Martha did attempt to intervene with Thaddeus’s traditional smoking years ago when she got wind of the e-cigarette. It had just come into the Canadian market and was being touted as the answer to those who want to quit smoking. So she bought a starter kit from a vape store and attempted to send it to her brother.
But both Canada Post and the courier companies stopped her. They didn’t have a problem shipping the e-cigarette unit, but they refused to transport the battery because it was combustible. Since it was proprietary to the device—it wasn’t the typical AAA battery—there was no point in sending the kit without it.
Meanwhile, Thaddeus had discovered e-cigarettes on his own. Martha didn’t know about this until she saw him with one on social media.
So what is it?
An e-cigarette is a device shaped like a cigarette or pen with a liquid that is vaporized (heated) and the resulting aerosol inhaled. Thus, the nickname, ‘vape’. The solution, called ‘e-liquid’, usually contains nicotine (the addictive drug in tobacco), ﬂavours, and a moistening agent for creating the aerosol. Newer versions, called ‘mods’, have more sophisticated casings. Brands vary in the amount of nicotine they contain. Vape devices from Juul labs contain high levels.
The Food and Drug Administration (FDA) approved many of the ﬂavourings and humectants in e-liquids for oral consumption, but not for inhalation, because there is not enough research to support claims of safety .
Even though e-cigarette use is called ‘vaping’, the devices produce an aerosol, not a vapor, which is a substance in gas form. The aerosol from an e-cigarette contains tiny chemical particles from both the liquid and the device. These can include metals from the heating coil.
An e-cigarette simulates the tobacco-smoking experience. As this alternative nicotine-delivery system was originally meant for those who want to quit smoking—and some manufacturers claim that their products don’t contain nicotine—the public assumes that they are safer than traditional cigarettes and therefore not addictive.
But are they?
Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA), explains that because many e-cigarette products deliver nicotine (which activates dopamine neurons in the brain), they provide a powerful way to condition users to other stimulants. The e-cigarette ﬂavours, smells, and nicotine reinforce the appeal.
“This is a terrible combination for accelerating the addictiveness of a product.”
In a NIDA TV interview discussing his e-cigarette research, Virginia Commonwealth University Professor of Psychology Dr. Thomas Eissenberg said that nicotine from both vapes and ordinary cigarettes is extracted from the tobacco plant. So, same drug, same biological basis.
“Nicotine is a psychomotor stimulant. It excites muscles at the level of the neuromuscular junction,” explains Dr. Eissenberg. “At low doses, it has a mild excitatory eﬀect like caﬀeine. At high doses, it can cause seizures and death. Unlike caﬀeine, it’s very easy to overdose on nicotine.”
Are e-cigarettes safer to use than regular ones, though?
The World Health Organization (WHO) estimates their safety risk as similar to that of smokeless tobacco, which has about 1% of the mortality risk of traditional cigarettes.
Johns Hopkins Medical Center cardiologist Dr. Michael Joseph Blaha conﬁrms the potential dangers of vaping, and encourages people to avoid cigarettes and their electronic alternatives. He says that some e-cigarettes and vape ‘juices’ contain a high level of nicotine. The FDA classiﬁes e-cigarettes and nicotine-laced e-juice as tobacco products and regulates them accordingly. The minimum age for buying e-cigarettes is 18.
The FDA views tobacco products as a ‘modiﬁed risk’ that causes less harm than smoking. There’s no combustion of tobacco, so users avoid harmful chemicals in tobacco smoke, like ash, tar, and carbon monoxide.
“This doesn’t mean e-cigarettes are safe. Many kids don’t know there is nicotine in e-cigarettes,” Dr. Blaha reminds parents.
It’s not just the nicotine that’s alarming. The Truth Initiative, America’s largest non-proﬁt public health organization committed to eradicating tobacco use—and best known for its youth smoking prevention campaign—lists about 60 chemical compounds in e-liquids and more in the resulting aerosol after heating. Some e-cigarettes release formaldehyde, a possible cancer agent . In a recent study, ﬁve carcinogens were found in the urine samples of e-cig users aged 16 .
Doctors advise guardians of young e-cig users to warn them of the dangers of vaping. Paediatrician Dr. Anita Chandra cites tips from the American Academy of Pediatrics: “E-cigarettes can be just as addictive as regular ones—especially true for still developing adolescent brains.” She advises parents to know the different e-cigarette formats, what they look like, and what they’re called: e-cigs, vapes, vape pens, mods, pods, and tanks.
Is the e-cigarette a gateway to traditional smoking?
Dr. Chandra says, “Teens who start with e-cigarettes take up others forms of tobacco.” Dr. Blaha conﬁrms, “People who start using e-cigarettes are more likely to go on to use other illicit drugs or to smoke later in life.”
Dr. Gopal Bhatnagar, a Canadian heart surgeon and co-founder of 180 Smoke (a vape retail chain), disagrees: “It’s comprehensively not a gateway. The game right now is to get people from combustible (cigars) to non-combustible products. Forget the morality. Look at the science of it. (Vaping) is safer.”
Of course, some would scoﬀ at Dr. Bhatnagar’s statement, seeing as he owns an e-cig business.
Can e-cigs really be used as a smoking cessation aid?
In England, e-cigarettes have been approved as safer alternatives to regular smoking.
In Canada, ﬁve million Canadians still smoke the traditional way. When asked if e-cigarettes could help wean them over to a safer nicotine delivery device, many ex-smokers say yes. Health Canada has not yet endorsed e-cigarettes with nicotine, but it is on the verge of deciding how these should be regulated. The Canada Vaping Association estimates the vaping industry in Canada to be worth $235 million a year.
In the USA, it’s a $2.5 billion business. The role of e-cigarettes in converting smokers into nonsmokers has created a rift between conservatives supporting it and liberals opposing it. The American Heart Association (AHA) says e-cigs don’t seem to aid smoking cessation eﬀorts.
Who uses e-cigarettes?
E-cigarettes have become the most popular tobacco product with young people, according to the 2018 Monitoring the Future (MTF) survey. MTF is one of three major surveys supported by the US Department of Health and Human Services providing statistics on youth substance use.
To determine user demographics, we look at statistics from various organisations:
The Truth Initiative
E-cigarette use among high schoolers rose from 1.5% in 2011 to 11.7% in 2017. The Truth Initiative also reported that Juul has cornered 68% of the e-cigarette market in just two years.
- One in ﬁve Americans under age 30 vape at least occasionally.
- Vaping is much less common among those 30 and older.
- 22% of 18- to 29-year-olds say vaping is “very harmful.”
- 83% of this group say this about smoking in general
E-cigarettes are more likely to be used by alcohol drinkers and former cigarette smokers.
Survey in the Annals of Internal Medicine 
- Current smokers and recent quitters are the groups in which e-cig use is highest.
- One in three e-cigarette users vape every day.
- E-cigarette users in the study who never smoked traditional cigarettes: 1.4%; ex-smokers: 7.6%; current smokers: 14.4%.
- Men (5.9%) vaped more often than women (3.7%).
- Vaping is more common and current among sexual minorities: 7% lesbians and gays, 9% bisexuals, and 8.7% transgenders.
- Those with chronic medical conditions like heart disease, lung cancer, and breathing disorders are more likely to vape than individuals without these conditions.
“Most e-cigarette users are smokers of conventional cigarettes, and LGBTQ adults are more likely to smoke conventional cigarettes, so the prevalence of e-cigarette use is higher among them,” says Dr. Nancy Rigotti, Director of the Tobacco Research and Treatment Center at Massachusetts General Hospital and a professor at Harvard Medical School in Boston.
The above survey results were based on self-reported entries not veriﬁed by medical records. Also, researchers didn’t know the e-cigarette categories used.
Johns Hopkins Medical Center
40% of young e-cigarette users have never smoked regular tobacco.
University of California, San Francisco
According to a new study published August 22, 2018 in the American Journal of Preventive Medicine, the risk of heart attacks is double for daily e-cigarette users. This is the ﬁrst study that examines the relationship between e-cigarette use and heart attacks.
A 2018 study showed that in the past year, more than 17% of 8th graders, 32% of 10th graders, and 37% of 12th graders vaped.
2018 National Youth Tobacco Survey (NYTS)
Vaping among middle and high school students increased between 2017 and 2018, with over 3.6 million kids currently using e-cigarettes in 2018.
Why do teenagers use e-cigarettes?
Dr. Volkow explores why teens are attracted to vaping: “It’s the appeal of new technology. Kids see it as a new gadget with a cool, sleek exterior.”
- Some e-cigarettes are packaged to appeal to the younger set. For instance, Juuls look like USB ﬂash drives.
- Some brands are made to look like food with enticing packaging to lure teenagers, many of whom lack impulse control. Teens discover e-cigs by accident this way.
- Kids find them more socially acceptable to use compared to regular cigarettes, which have acquired bad rap in certain circles.
- Vaping devices can also be used by teens to ingest 9THC, the active ingredient of marijuana. One can put in a concentrate that is almost 100%. This makes adverse effects worse.
Do e-cigs explode?
Teenager Austin Burton had an e-cigarette explode in his mouth in March 2018. His lower jaw was fractured, and one piece and many teeth went missing, requiring surgeons to put a plate under his gums. They weren’t sure if the battery caused the explosion. Austin used the VGOD brand, which promotes ‘tricking’—creating rings and unusual shapes with a large vaping cloud.
Dr. Katie W. Russell, a pediatric surgeon at the University of Utah, and Dr. Micah Katz, both of whom treated Austin, submitted his case to The New England Journal of Medicine to warn the public about the dangers of vaping.
Can one die from using e-cigarettes?
In August, The Washington Post reported the ﬁrst death from lung disease linked to e-cigarettes. Illinois state and federal health oﬃcials are now investigating other lung illnesses connected to vaping. The CDC cites 193 cases in 22 states, many involving teens and young adults.
Health oﬃcials are wondering why vaping-related illnesses have only started surfacing recently when vape devices have been around for more than 10 years. Brian King, Deputy Director for Research Translation, CDC Oﬃce on Smoking and Health, said there were previous cases but the CDC “wasn’t capturing them.” He said substances in e-cigarette aerosol can contain ingredients potentially harmful to lung health and have been linked to respiratory ailments. Authorities admit that they don’t know whether the illnesses are associated with the vaping devices only, or with the inhaled ingredients.
In an interview with CBS News, outgoing FDA Commissioner Scott Gottlieb said the government is investigating a possible link between e-cigarette use and seizures in children and young adults. He cited 35 reports between 2010 and 2019 of people suffering from seizures after vaping.
Thaddeus’s story was told on a personal level. It does not implicate the vaping industry, as his death was not solely attributed to vape use, and e-cigarettes weren’t mentioned in his death certiﬁcate. But his experience should make one think.
Health officials are warning the public of a teenage vaping epidemic. They advise those who experience any type of chest pain or difficulty breathing after vaping to seek immediate medical attention and to consult the FDA’s Safety Reporting Portal. They recommend that caregivers of patients with sudden respiratory illness ask if they vape.
Gottlieb said e-cigarettes “can offer an alternative for currently addicted adult smokers to migrate off combustible cigarettes onto something with fewer health risks. But it can’t come at the expense of addicting a whole generation of kids onto nicotine through these products.” He added that if more negative e-cigarette events involving youth surface, the FDA could ban e-cigarettes to stop teenage access.
The National African American Tobacco Prevention Network Research shows that a menthol ban could save millions of lives and reduce youth initiation to tobacco.
The American Lung Association calls for greater electronic cigarette regulation.
Cooperation from the leading e-cigarette brand
Juul said it is tracking reports of (vape-related) illnesses and has “robust safety monitoring systems in place.” It is also preventing use of its products by underage youth through the imposition of stricter online purchasing controls. They took their most enticing flavours off the shelf, only making these available online with age-compliant restrictions.
To prevent bulk purchases and resale to minors, they implemented product-tracking systems, two-factor authentication, and face-recognition methods. Buyers now have to upload photos with their government-issued IDs if their personal information can’t be verified.
They do compliance checks and warn retailers against violations. They also minimized their advertising on social media by discontinuing their Facebook and Instagram accounts. They’ve developed a Bluetooth device that imposes age restrictions. They also posted the dangers of using their product on their website in capital letters.
Since the long-term effects of e-cigarettes are unknown, and contradiction abounds in studies and claims, it is best to err on the side of caution and avoid the use of a technology that is still evolving. Perhaps after more compelling evidence of their safety has been established—and the FDA and other authorities have stamped their approval—the public can decide.
Photo credit: E-Cig Twigg. This picture has a Creative Commons attribution license.