Vaping: There’s No Smoke Without Fire

With claims about e-cigarettes and vapes leading to the death of at least 18 people worldwide[1], Electronic Nicotine Delivery Systems (ENDS) have earned a spotlight in the news. ENDS is an all-encompassing term for electronic cigarettes, vapes, e-pipes, e-hookahs etc[2]. According to an article in The Guardian, there are more than 1,000 confirmed or probable cases of vaping-related lung injuries across the US[3]. These numbers have been corroborated by the Centre for Disease Prevention and Control (CDC)[4].

On 26 July 2019, the World Health Organisation (WHO) issued a report[5] warning that electronic cigarettes are “undoubtedly harmful” and should be regulated. According to the report, E-cigarette use has skyrocketed in recent years, growing by an staggering 900% among high-school students from 2011 to 2015[6]. The numbers of vaping-related lung injuries are bound to rise as an estimated 2.9 million adults in Great Britain alone currently use e-cigarettes[7].

According to the CDC, the use of e-cigs is unsafe for kids, teens and young adults[8]. The NHS website states that nicotine is addictive yet relatively harmless[9]. Nicotine is an ingredient used in ENDS. Contrary to the NHS, in 2016 the US Department of Health and Human Services published a report on e-cigarette use among young adults, which suggests nicotine exposure can harm brain development and lead to other serious consequences[10].

According to this report by the Department of Health and Human Services, what is most alarming is the growing number of young ENDS users, despite the potential implications on brain developments in adolescence. The Report states that “The most commonly cited reasons for using e-cigarettes among both youth and young adults are curiosity, flavouring/taste, and low perceived harm compared to other tobacco products. The use of e-cigarettes as an aid to quit conventional cigarettes is not reported as a primary reason for use among youth and young adults.” Their findings also suggest that flavoured e-cigarettes are more commonly used by young adults (aged 18-24 years) as opposed to older adults (aged 25 years and above).

Lung-Related Injuries and Mechanisms of Harm

The aetiology of these long-related illnesses are unknown but they do not appear to be infection-mediated. There are a number of compounds in vapes that could potentially cause injury including flavourants, volatile organic compounds and heavy metals including nickel, tin and lead[11].

According to an Information Series in the American Thoracic Society, lung-related illnesses caused due to vaping are variable and non-specific. They include elevated white blood cell count, erythrocyte sedimentation rates, CT scans of lung infiltrations, neutrophilia and sparse to moderate lipid laden macrophages.

The following are some reported lung-related illnesses caused by vaping[12]:

  • Acute eosinophilic pneumonia
  • Lipoid pneumonia
  • Acute lung injury and acute respiratory distress syndrome
  • Acute and subacute hypersensitivity pneumonitis
  • Organising pneumonia
  • Acute eosinophilic pneumonia
  • Diffuses alveolar haemorrhage
  • Respiratory bronchitis-associated pneumonia

Patients have also reported symptoms of shortness of breath, fever, cough, vomiting, diarrhoea, headaches, dizziness, chest pain etc following the use of vaping devices.

The WHO report states that although ENDS pose risks to both users and non-users, there is insufficient evidence to quantify this risk and the long-term effects of exposure to ENDS’ toxic emissions are unknown.

To conclude, there is a lot of conflicting information with regards to the effect of vaping on respiratory illnesses. According to the BBC, the outbreak is very prevalent in the US compared to the UK. This is because all e-cigarette products are tightly controlled under stricter regulations in the UK.

Current position

According to the WHO report:

Recent surveys in the United States of America (USA) and some European countries have shown marked increases in ENDS use amongst youth. Between 2011 and 2018 in the USA, youth e-cigarette use rates have risen from 1.5% to a staggering 20.8%. Young people who use ENDS are exposed to nicotine, which can have long-term effects on the developing brain and there is a risk of nicotine addiction, given that tobacco product use is primarily established in adolescence…”

Similar concerns have been raised by San Francisco officials who have banned the sale of e-cigarettes within the city[13] despite the fact the full extent of the health risks are still largely unknown. That said momentum appears to be growing and an increasing number of studies/reported cases suggest e-cigarettes are likely to cause harm i.e.:

“A full investigation is not yet available but we’ve heard reports that most of these cases were linked to people using illicit vaping fluid bought on the streets or homemade, some containing cannabis products, like THC, or synthetic cannabinoids, like Spice.”

“An investigation by Harvard University[14] found that more than one in four of the increasingly popular products harboured bugs known to cause asthma, inflammation and reduced lung function.”

“… findings indicate that e-cigarettes are a potential source of exposure to toxic metals (Cr, Ni, and Pb), and to metals that are toxic when inhaled (Mn and Zn) …”

“ I, Surgeon General of the United States Public Health Service, VADM Jerome Adams, am emphasizing the importance of protecting our children from a lifetime of nicotine addiction and associated health risks by immediately addressing the epidemic of youth e-cigarette use. The recent surge in e-cigarette use among youth, which has been fueled by new types of e-cigarettes that have recently entered the market, is a cause for great concern”

The WHO Report suggests that Member States that have not banned ENDS should consider regulating them as harmful products and market them in the same way as tobacco products. This is because public health officials are concerned that these devices may serve as a gateway to conventional smoking among young people.

As the vaping backlash grows, countries like India, Malaysia, Thailand, and the US are pushing for tough anti-e-cigarette laws and also placing bans on these products.

To summarise

ENDS are currently marketed and promoted as healthier/cleaner alternatives to conventional smoking of tobacco. While this may be true, it is important to note that ENDS are not risk free, and that the long-term impact on health and mortality is unknown. Reviews on the health effects of ENDS have been inconclusive and conflicting, and further research in this field is warranted.















One Reply to “Vaping: There’s No Smoke Without Fire”

  1. Its interesting to note that Vaping is now being banned in the developing economies of the world, while despite all the brouhaha, it is still thriving in the UK.


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