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Eukaryon

A New Public Health Hazard: Vaping

Helen Brinckerhoff
Department of Biology
Lake Forest College
Lake Forest, Illinois 60045

Introduction

The use of electronic cigarettes (otherwise known as e-cigarettes, e-cigs, vaporizers, and vapes) has taken off since they were first introduced to the market as a way of cutting back on and eliminating traditional smoking. People generally tend to recognize the need to end the 480,000 deaths per year that are associated with smoking. Vaping initially appeared to be a better alternative to tobacco use and an additional resource to help people quit a potentially dangerous and costly habit. A decade ago the e-cigarette market essentially did not exist, but since then has grown exponentially. E-cigarettes do not contain the elements that typically deter or annoy people about smoking, such as the distinctive and lasting smell, acrid or burnt taste, and the ever-present smoker’s cough. As the practice of e-cigarette use has gone mainstream, a whole new vaping culture has arisen, with protocols of proper usage and terminology. Vape shops are becoming as common and easy to find as McDonalds across the United States. People concerned with public health are now scrambling to catch up, as the prevalence of use of these non-traditional smoking practices increases. Of significant concern are the effects that the use of these non-traditional nicotine transmitters will have on the public at large. It is unclear how many people are directly or indirectly being affected or becoming sick from e-cigarettes nor is it yet known what the long-term effects will be on a new generation of e-cigarette users. However, it is becoming clear that the consequences of this vaping epidemic will be far reaching due to the fact that there is an unintended consumer, the teenager. The e-cigarette market has grown into a practice that is far beyond merely smoking prevention.

Demographics

E-cigarettes were imported to the US from China in 2006 (“Before You Vape,” 2015). Historically, the first vaporizer was developed as early as just before 1930 (Snowdon, 2017). Today, 3.7 percent of the US population, or approximately nine million Americans, are reported to have tried vaping (Schoenborn and Gindi, 2015). At the same time, the number of tobacco smokers has reduced to an all-time low of 15 percent (CDC, 2018). While this may appear to be a good indication that e-cigarettes are helping traditional smokers move away from tobacco use, in reality this correlation may not equal causation. The number of people who now are vaping has been increasing due to a multiplicity of factors, other than merely a desire to turn away from tobacco use. Because of this, people across the world worry that vaping will grow to become an even larger problem, with unknown consequences that have yet to be identified. A look at the e-cigarette world market shows that it has grown from a twenty-million-dollar industry to a ten-billion-dollar industry in 2017 (Figure 3 appendix) (Statista, 2018). It is projected that by 2023 the industry will grow to around $48 billion (P&S Market Research, 2018). The US portion of that market alone is currently valued at close to $3 billion.

Vaping, or the use of e-cigarettes, is not a public health issue that is linked to any one ethnic or occupational group, but rather it appears to be a lifestyle choice that is similar to alcohol, tobacco, or marijuana. People freely choose to spend their disposable incomes to buy this non-essential item. Men (60.7%) are more likely to vape than women (39.3%). Non-Hispanic whites (62.9%) are more likely to vape than any other ethnic group (Figure 2 appendix) (Pepper, 2018).  For cigarette smokers who are trying to withdraw from the addiction of tobacco, e-cigarettes allow them to maintain the connotations of an existing social practice. The use of e-cigarettes is similar to traditional tobacco cigarette use because it has been shown to occur most often in social settings and in groups (Figure 2 appendix) (Pepper, 2018).

Vaping now appears to be more appealing to the youth of America than tobacco cigarettes. It is seen as a highly addictive product for these young people because of the attractive and vast array of products, with hundreds of new devices and thousands of new flavors currently being sold. An analysis of high school nicotine usage revealed that, despite the decline of cigarette use overall, nicotine usage remains the same because of the sharp uptrend of e-cigarette use (Figure 1 appendix) (Reason.com).

A good example of what is currently on the market is an e-cigarette product called the “Juul”, which was developed in the past 2 years and has since then taken over more than 50% of the vaping market (Satel, 2018). A Juul is nondescript and simple to use, with a sleek design and easy to refill pod. It slips into a pocket comfortably and even comes with a built in USB charger. A Juul starter kit costs as little as $50 dollars, which in part may explain why the popularity of ‘Juuling’ is exploding. As a result, schools and parents are now scrambling to respond to what is becoming a new problem. Students go into bathrooms and the library to congregate and ‘hit their Juuls’. They are entertained and entertain others by doing smoke tricks, and its forbidden nature makes vaping appear to be something exciting, with less risk of being caught due to odor. A pod (the Juul refill) is less expensive than a pack of cigarettes and the concentration of nicotine in a Juul pod is higher than what is found in most other forms of e-cigarettes.

To further the problem, the  cheap cost of Juuls helps encourage adult smokers to move away from buying packs of cigarettes. It is logical to choose the cheaper form of getting a fix of nicotine based on the calculations of how much a person would spend on packs versus on pod replacements. A major complaint tobacco smokers have is that smoking is an expensive habit and one that is unnecessarily burdensome. They now are able to “save” money by choosing e-cigarettes instead of tobacco cigarettes. Therefore, this conflates the issue of how these products should be priced; i.e., how to avoid encouraging non-users to begin using a nicotine delivery product, while attempting to be competitive in the marketplace in order to gain customers and save the lives of traditional smokers.

Factors causing the problem

The carcinogens present, the nicotine itself, the convenience and accessibility, the cheaper price, and the attractiveness of the product are all factors that contribute to the vaping problem we now face. People mistakenly believe that the use of e-cigarettes is completely safe because the negative aspect of inhaling burning tobacco smoke is not present. It is true that the person who is vaping is not inhaling tar or experiencing the burnt lungs that we now associate with smoking tobacco. However, toxins are indeed present in both e-cigarette vapor and the flavoring that is being delivered to the lungs, even though the lungs are not being affected or blackened as they are with tobacco use. It is clear that vaping is not delivering just harmless water vapor.

The Center of Disease Control and Prevention looked into what is actually being inhaled when using the electronic cigarette and identified several cancer-causing substances, one of the most significant being high levels of formaldehyde (NBC News, 2015). Formaldehyde is produced in an e-cigarette through the process of heating up and cooking the vape juice.  It is important to acknowledge that this is the chemical used for embalming bodies. When formaldehyde is inhaled into the lungs, in this case from an e-cigarette, it begins to change and breakdown the tissues of the mouth, nose, and throat and is linked to cancers such as leukemia (Palazzolo, 2013). In addition, a New England Journal of Medicine study shows that inhaling e-cigarette vapor at a high voltage (5.0 V or higher) releases larger amounts of formaldehyde, while vaping at low voltages (3.3 V or lower) releases no formaldehyde. (Jensen and Luo, 2015) Therefore, a strong causation was established between the vape temperature and the amount of carcinogenic formaldehyde that was released. An obvious possible solution to the presence of this carcinogen would be to consume vapor at a lower voltage. However, voltage settings can be controlled only in certain types of e-cigarettes and those types are the bulkier devices that are becoming less popular. In addition, no warnings are present on e-cigarette products about formaldehyde and voltage, or the presence of other carcinogens. This creates a disconnect between the users’ understanding and awareness. If the public is not made aware of this study and warned of side effects, they will not understand the need to turn down the voltage or have the information they need to best choose which device to buy.

In addition, the CDC study indicated that the amount of nicotine present in e-cigarettes is problematic. Nicotine itself has known adverse side effects (Palazzolo). Nicotine is the highly addictive agent that is found in tobacco, and nicotine is also present in e-cigarettes. Nicotine is known to be dangerous because it directly leads to addictive dependency (Palazzolo). While nicotine is not directly linked with the contraction of cancer (Niaura), further general studies have proven that nicotine is harmful for brain development (Niaura; Pepper). This factor becomes especially problematic in the case of e-cigarettes because so many of the consumers who are attracted to this product happen to be young people. ​ Well before China introduced e-cigarettes in the US in 2006, the FDA actually had developed and released the government’s version of vaporizer/ e-cigarette products (1998) (Palazzolo). These were “nicotine inhaler” prototypes that delivered pre-measured and controlled amounts of nicotine, which ensured regularity and prevented inconsistencies of delivery. However, users did not like the FDA approved product experience as much as they later would with the e-cigarette experience ​(Palazzolo). Even though the inhaled amounts were regulated and evenly spaced so that nicotine inhalation was more easily controlled, the customers’ overall reaction was negative, and the FDA product is not widely used.

Another factor to be considered is the increasing amount of vaping that take place in schools, which could lead to an overall deterioration of public health. Schools are recognized to be the repositories of germs because of students’ proximity to each other and their movements throughout the building. The look and feel of e-cigarettes incentivize them to pass around and repeatedly share this piece of plastic. This sharing exacerbates the transfer of germs within a building through a new and direct mode of transmission. Further study needs to be done on the use of e-cigarettes in schools to determine whether a correlation exists between e-cigarette use and the number of reported illnesses such as influenza or mononucleosis. Students who share vapes with someone who is sick, or who is a carrier for a virus or bacteria, cause more people to be infected at school because those germs are now moving from student to student more freely. As more students become sick, they go home to family members and transfer those germs to family members. These family members then go to work and infect others, and the germ cycle spreads. Even those individuals who do not choose to vape are at risk to become infected and there may be a corresponding overall increase of germs being passed around in our country. This is an issue that could have a bigger impact than anyone currently anticipates.

A fundamental problem with e-cigarettes exists because to date there is no clear evidence to support the claim that they do actually help people to quit smoking. In fact, there is actual evidence which shows that vaping is not as effective as other methods of smoking cessation, such as nicotine gum or patches. Vapes were studied as a smoking cessation aid in a study of 657 people (Bullen, 2013). Of that study group, 289 participants were placed on nicotine vapes. By the end of the study, only 21 of the 289 participants were able to escape their nicotine addiction. Of the 73 people placed on nicotine-free vapes, 3 were able to escape their nicotine addiction​ (Bullen). This would indicate that if one is trying to quit smoking by using another smoking tool, that person is more likely to be merely trading one dependency for another and therefore unlikely to escape addiction. The physical act of smoking is one that is psychologically addictive (Palazzolo). It is a methodical and somewhat meditative practice that helps people to relax, to think, and perhaps to focus on their well-being. Therefore, since the physical act and experience of vaping is so similar to that of cigarette smoking, it is relatively easy to transition from one product to the other, which is not the case with other methods such as gum, spray, or patches. When vaping, the smoker is still able to experience the act of smoking and receives instant gratification. However, progress toward recovery is impeded because vaping is easily abused, making it less likely to really kick the habit.  Also, it is possible for smokers to simply use e-cigarettes as a delivery system for nicotine in places where it is not allowed for them to smoke a cigarette. Further studies will also need to look at whether or not this and the next generation of young people, who have become nicotine dependent because of vaping, will turn to smoking cigarettes later in life.  Only time and further study can tell us if there are gateway effects.

Public health response and its effectiveness

Based on backlash from the public, change is coming in both private business practices and institutionally. Recently, in August 2017, Juul raised the minimum age to buy products on their website from the age of eighteen to twenty-one. Under the Food and Drug Administration Regulations, the US as of 2016 classifies e-cigarette products as tobacco products and businesses selling vaping items can no longer offer free sampling of vape flavors to their customers. In addition, e-cigarettes cannot be marketed as a “modified risk” product. In other words, when advertising an e-cigarette, the seller cannot say that it is a healthier alternative to smoking.

Recently, there has been a push at the state-level towards an increased use of taxes on electronic cigarettes and their accessories in an attempt to control consumption. This is a tactic referred to as a ‘sin tax’, similar to the taxes placed on alcohol and cigarettes by most states. In Minnesota, e-cigarette products are taxed as high as 95% over wholesale costs (Blair, 2015)​. In North Carolina, these products are taxed at 5 cents per mL of fluid per product (about 2.5 cents extra per product) (Blair).​ Seven other states have placed additional taxes on e-cigarette products as well. It may be a good idea to watch how well this works on the state level, to determine whether the use of higher taxes is effective in reducing the number of people who claim that they vape.

More education​ about the risks associated with vaping is needed. Many e-cigarette users do not know about the harmful effects of vaping​ because they have not been informed about them. This is a potential public health issue that should be exposed and explained now. There needs to be a push for education campaigns and ads, similar to what has been done in the past for alcohol, drugs, and cigarettes, to expose the public, especially students, to the potential dangers of using an e-cigarette. This could prompt current users to quit and deter non-users from starting to vape, similar to the “say no to drugs, alcohol, and cigarettes” campaigns that have appeared in the past on assignment notebooks in grade schools.

Every week articles appear in various newspapers that warn the public against the use of e-cigarettes.  Recently on Snapchat there have been multiple comprehensive posts warning about vaping. This is relevant because Snapchat is an application that is more specifically targeted toward younger people than other sites. These young people are not reading newspapers. Snapchat is being used to reach an audience that would not necessarily be exposed to traditional media sources and their information outlets. This tactic is very smart. Public health is about meeting people where they are, to help them make better and more-informed life decisions. Therefore, the consumers who are most in need of information about the potential health risks associated with vaping are the ones who use Snapchat. Former smokers are more likely to be aware of the potential dangers and drawbacks of living a life of nicotine dependency,but young first-time users are making choices without being fully aware of the potential consequences.

Doctors themselves are conflicted when dealing with patients who are trying to quit smoking. Since vaping has occurred relatively recently, the medical community does not yet seem to have a cohesive position when presented with a patient who smokes tobacco and is trying to quit (Gucht, et al, 2016). Some medical professionals encourage the use of e-cigarettes as an alternative to tobacco, perhaps because they are unaware of its potential risks, or perhaps because the risks associated with the use of tobacco outweigh the risks of vaping. 

Conclusion

The use of electronic cigarettes as an alternative to tobacco use is becoming more prevalent in the United States. Research has shown that e-cigarettes are not only as addictive as  tobacco cigarettes, but they also can be unsafe. Nevertheless, what was once merely a fad is now a practice that appears to have become mainstream and accepted as a part of social interactions. A growing number of people are choosing e-cigarettes and this choice is trickling down to include growing numbers of young people as well. The currently known risks associated with vaping are significant, and more research and study has yet to be done. While public health concerns are mounting, no public warning campaigns have begun, and young people especially are at risk. The large numbers of people who are using e-cigarettes should be informed and cautioned about the risks associated with vaping so they are better able to choose whether they want to participate in “vape life.”

 

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Appendix

Brinckerhoff Fig 1

 

Figure 1

 

Brinckerhoff Fig 2.1

Brinckerhoff Fig 2.2

 

Figure 2

 

Brinckerhoff Fig 3

 

Figure 3

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Eukaryon is published by students at Lake Forest College, who are solely responsible for its content. The views expressed in Eukaryon do not necessarily reflect those of the College.

Articles published within Eukaryon should not be cited in bibliographies. Material contained herein should be treated as personal communication and should be cited as such only with the consent of the author.