To Vape or not to Vape? It's no longer a question, by Irina Foxman, ANP

E-cigarettes are devices that deliver nicotine using a battery, a heating element, and a container of liquid. When the liquid is heated, users inhale the aerosol. The liquids are usually flavored and contain nicotine, so users experience a taste sensation in addition to a dose of the addictive stimulant found in cigarettes. The multitude of flavors (as many as 7,000 flavors) including mango, fruit, and crème are particularly appealing to the younger age group. These flavors are believed to contribute to habitual use and possibly addiction. E-cigarettes were initially put on the market to help smokers quit smoking. However, the Food and Drug Administration (FDA) has never found any e-cigarette to be safe and effective in helping smokers quit.
E-cigarettes come in different shapes and sizes. Some look like regular cigarettes, cigars, or pipes. Some e-cigarettes look like pens and other everyday items such as a USB flash drive, most commonly known as JUUL. The JUUL is very popular among younger people because it’s easy to conceal and it comes with flavorings. It is the top-selling e-cigarette brand in the United States. It is so popular, that a new verb, “Juuling” is now widely used (the equivalent term is “vaping”). JUUL’s nicotine liquid refills are called “pods”. A single JUUL pod can contain as much nicotine as a pack of 20 regular cigarettes. JUUL delivers nicotine in a new form called “nicotine salts,” which can make it less harsh on the throat and easier to use by youth. Additionally, JUUL can be filled with higher-nicotine-content liquids than other e-cigarettes. The JUUL company website claims to be working with the government to prevent any sales to young people. Despite the extensive existing research on carcinogenic effects of nicotine, the JUUL website states incorrectly that nicotine does NOT cause cancer; they do admit that it is habit forming.
Since e-cigarettes are reasonably new, scientists are still learning about the long-term health effects of e-cigarette smoking. There are known adverse effects of nicotine when it’s ingested or inhaled by an individual. Nicotine exposure during adolescence is known to harm brain development. This effect continues until about the age of 25 according to the Centers for Disease Control and Prevention (CDC). Nicotine exposure can also impact learning, memory, and attention, as well as increasing the risk for future addiction to other drugs. Young people who use e-cigarettes may be more likely to go on to use regular cigarettes (Office of the Surgeon General, 2014). More recently (Aug 12, 2019), the US Food and Drug Administration is investigating 127 reports of seizures, tremors, fainting and other neurological syndromes that may be related to electronic cigarettes. The effects of nicotine can also affect the cardiovascular system. Cardiovascular side effects include chest pain, increased blood pressure, and increased heart rate, and narrowing of the arteries; all these problems can lead to heart disease. There is not yet enough evidence that e-cigarette use can lead to long-term changes in blood pressure and heart rate. There are also gastrointestinal side effects secondary to nicotine use such as an upset stomach or nausea, deteriorating gum disease and erosion, discoloration of teeth. Chronic nicotine use may lead to insulin resistance and type 2 diabetes.
E-cigarette aerosol contains other harmful substances including other cancer-causing chemicals, volatile organic compounds and ultra-fine particles. Flavorings have been linked to lung disease and an increase in heavy metals such as nickel, tin, and lead. The major components of e-liquids such as propylene glycol and glycerol are not thought to be dangerous on their own. However, when they are heated by the vaporizer, they are transformed into toxic compounds such as formaldehyde. Dangerous chemicals such as aldehydes in e-cigarettes can cause lung disease and cardiovascular (heart) disease. In January 2018, The National Academies of Science, Engineering and Medicine released a study report in which they reviewed over 800 different studies. This report concluded that there is moderate evidence that youth who use e-cigarettes are at an increased risk for cough, wheezing and an increase in asthma exacerbations due to the exposure of potentially toxic substances emitted when using e-cigarettes. In addition, E-cigarettes also contain acrolein, a herbicide primarily used to kill weeds that can cause lung injury and COPD and may cause asthma and lung cancer. Many more components of e-cigarette liquids are unknown because e-cigarette users buy these substances off the street and modify or add additional ingredients. None of these substances have been studied when they are heated and inhaled.
The US Surgeon General has also warned users about the risks of inhaling secondhand and e-cigarette emissions. The risks of second hand vapor are unknown but are expected to be lower than tobacco smoke. Caution is recommended around non-users, youth, pregnant women, and people with cardiovascular conditions. Since many e-liquids have candy and fruit flavoring and packaging that makes them attractive to children, both children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes (CDC). Rarely, e-cigarettes have been associated with explosions (due to the lithium battery) and fires causing serious burns and death (US Fire Administration 2009-2016). Although rules vary, many public places such as airplanes, hotels, and hospitals prohibit e-cigarettes and vaping as part of their non-smoking policies. E-cigarettes can trigger some types of fire alarms.
Electronic cigarettes (e-cigarettes) entered the US market around 2007. Since 2014, they have been the most commonly used tobacco products among youth. During 2017 and 2018, e-cigarette use skyrocketed among youth in the US. E-cigarette use in teens rose 78 percent nationwide, from 11.7 percent to 20.8 percent according to the CDC. In 2018, more than 3.6 million US youth, including 1 in 5 high school students and 1 in 20 middle school students, currently use e-cigarettes (CDC, 06/19). According to the World Health Organization, the global vapor products market is now estimated to be worth $22.6 billion, up from $4.2 billion just five years ago. The United States, Japan, and the UK are the biggest markets. The sales in these three countries account for $16.3 billion on smokeless tobacco and vaping products in 2016. E-cigarettes generated about 2.35 billion US dollars in sales in the United States in 2016. Manufacturers spent a total of $718.32 million on smokeless tobacco advertising and promotion in 2017. In 2017, tobacco companies spent $9.36 billion marketing cigarettes and smokeless tobacco in the United States. This amount translates to more than $25 million each day, or more than $1 million every hour (CDC). E-cigarettes are advertised over several different outlets such as television, retail stores, the internet, newspapers and magazines. Social media is also contributing widely to the younger people due to sharing products on newsfeeds and timelines on websites such as Facebooks and YouTube. Therefore, manufacturers are able to spend less money on advertising due the self-propagating nature, thus increasing their profits.
Smoking-related illness in the United States costs more than $300 billion each year. Nearly $170 billion for direct medical care for adults. More than $156 billion in lost productivity, including $5.6 billion in lost productivity due to secondhand smoke exposure. The FDA has instituted an adverse event reporting system which is a database of voluntary reports from patients, product manufacturers and health professionals and poison control centers across the country. The FDA regulates all aspects of e-cigarettes and vaping products including packaging, promotion, banning of ingredients and devices. On August 08, 2019, the FDA issued warning letters notifying four companies to remove 44 flavored e-liquids and hookah tobacco products from the market for not having required marketing authorization.

In November, 2018, JUUL suspended the distribution of Mango, Fruit, Crème, and Cucumber to traditional retail. These flavors are currently available only online with an enhanced online controls that are compliant with the JUUL’s restricted distribution system to 21 year old and older adults. Many states are working to push bills for the 2020 legislative year to tax e-cigarettes just like other tobacco products as a way to decrease use. At the federal level, US Sen. Mitch McConnell has a bill to raise the legal age to buy tobacco products to 21 years old nationwide. Currently, the legal buying age varies between 18 and 21 year old from state to state. There is no federal excise tax on e-cigarettes. However, some states have the authority to tax e-cigarettes.
There is much more to be learned about e-cigarettes. For now, they are largely unregulated, un-taxed and the use is rising due to self-propagating nature of today’s technology and social media. One thing is clear, nicotine is harmful to humans when it’s inhaled or ingested. Currently, CDC is investigating 805 cases of individuals with various stages of lung disease due to e-cigarette use. Thirteen deaths have been confirmed due to e-cigarettes as of September 28th, 2019 in several states. As far as college life is concerned, e-cigarettes are repeatedly shared among friends, which leads to various upper respiratory and communicable diseases. We have seen a sharp rise in illness at our student health center in the last few years in strep, upper respiratory infections, and mononucleosis. It is our recommendation not to share e-cigarettes and quit using them with the resources we can provide at the Loyola Student Health Center.
If smokers are ready to quit smoking for good, they should call 1-800-QUIT NOW or talk with their medical professional about finding the best way to quit with FDA-approved treatment and counseling.