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To Vape or Not to Vape, That is the Question

Electronic cigarettes (e-cigarettes) have become very popular in recent years, with shops springing up all over the country, and people surrounded by clouds of fragranced vapour wherever you go.

They are widely believed to be a safer alternative to smoking tobacco, but are they safe?

It’s been around 12 years since e-cigarettes became available in the UK. They work by heating a liquid that contains nicotine. The liquid then becomes a vapour that people breathe in, this is known as ‘vaping’. The e-cigarette gives smokers the nicotine hit they need to help beat their cravings, but the vapour doesn’t contain the same dangerous cocktail of chemicals found in tobacco smoke.

Cigarette smoke contains over 4,000 different compounds. A significant number of which are toxic and can damage our cells and many of which are carcinogenic. Cigarette smoking has been found to be linked to many different types of cancer and other diseases. A study by the American Cancer Society claims that almost half the deaths (48.5%) from 12 different types of cancer combined are attributable to cigarette smoking. Of these, lung cancer has the largest percentage of deaths attributable to smoking at 80.2%.

E-cigarette vapour doesn’t contain tar or many of the other toxins found in cigarette smoke and is billed as the healthier alternative to smoking. So, on the face of it, vaping can only be a good thing then, can’t it? E-cigarette sellers are certainly happy to focus on this and play down any risks associated with vaping. In 2009, Ruyan (an e-cigarette manufacturer) sponsored research which showed that e-cigarettes were 100 to 1000 times less dangerous than smoking tobacco so you can see why many people support their use as an alternative to tobacco.

However, what manufacturers may not wish you to focus on is that the vapour still contains cancer-causing chemicals such as formaldehyde, as well as flavourings which make vaping taste pleasant but can also contain cancer causing compounds and lung irritants. A common compound used is diacetyl which has been linked to a serious lung condition called bronchiolitis or ‘popcorn lung’.

Because vaping is a relatively new phenomenon we don’t yet have a view of how long-term usage affects people. However, a recent study carried out on mice by researchers from New York University School of Medicine, and funded by the US National Institutes of Health, showed that e-cigarette vapour is not risk free and that the nicotine solution may cause cell DNA damage that has the potential to cause cancer. They concluded that "Based on these results, we propose that ECS [electronic cigarette smoke] is carcinogenic and that e-cig smokers have a higher risk than non-smokers to develop lung and bladder cancer and heart diseases."

It is important to note that there are some limitations of this research though:

  • results from animal studies often don't translate into results in humans

  • results from isolated in vitro cell cultures, even from human cells, often don't translate into what happens in the human body

  • the mouse exposure to e-cigarette vapour was said to be comparable with 10 years' light e-cigarette use, but administering this over 12 weeks would mean the mice were exposed to very high levels of e-cigarette vapour – this concentrated exposure may have had a bigger effect on DNA repair than much lower exposures would have

  • the study did not look at the comparative damage of e-cigarette vapour versus tobacco smoke

Limitations aside it does raise questions over the safety of e-cigarette smoke though and it is something that certainly requires further investigation. It would be flippant to dismiss these findings given the issues raised.

Separately, researchers at the University of Rochester Medical Centre looked at the effect of e-cigarettes on oral health at the cellular level. They concluded that e-cigarettes are as damaging to the gums and teeth as conventional cigarettes. The study, published in Oncotarget, was led by Irfan Rahman, Ph.D. professor of Environmental Medicine at the UR School of Medicine and Dentistry he said “when the vapors from an e-cigarette are burned, it causes cells to release inflammatory proteins, which in turn aggravate stress within cells, resulting in damage that could lead to various oral diseases,” “How much and how often someone is smoking e-cigarettes will determine the extent of damage to the gums and oral cavity.”

This raises very real concerns over the possibility of oral cancers as a result of e-cigarette use. Dr Rahman would like to see manufacturers disclose all the materials and chemicals used in e-cigarettes, so consumers can become more educated about the potential dangers. He is also of the view that “More research, including long term and comparative studies, are needed to better understand the health effects of e-cigarettes,”.

While the focus of this paper relates to cancer it’s also important to acknowledge the other health risks, for example the impact on heart health. In February 2018 researchers from George Washington University and the UCSF Centre for Tobacco Control Research and Education found that daily e-cigarette usage doubled the risk fo heart attack. If e-cigarette smokers also continued to smoke regular cigarettes, their risk compounded by a factor of five.

All this indicates that it’s possibly not quite the healthy alternative it’s made out to be! This is a very important point; while it may be the lesser of two evils when it comes to tobacco smoke it is important that non-smokers do not see vaping as healthy or safe. There is a major concern with vaping being be a gateway for young people into smoking who would not have become tobacco users otherwise. Marketing has often been criticised for appealing to young people, particularly given the types of ‘flavours’ available.

Vaughan Rees, who is Director of the Centre for Global Tobacco Control at the Harvard T.H. Chan School of Public Health, believes that e-cigarettes can be a useful tool to help people quit smoking but his support ends where flavours are involved. "We're seeing a proliferation in flavors, including gummy bear and candy flavors that are intrinsically appealing to children." He believes it is "absolutely crucial" that use of these flavours is not endorsed.

In September 2015, research from the BMJ found that teens who used e-cigarettes were more than three times as likely to be smoking traditional cigarettes a year later and another study published in Pediatrics in 2018 found that youth who experiment with e-cigarettes were nearly two times more likely to become established smokers of regular tobacco cigarettes. Therefore, gateway risk is a real concern.

A separate issue is that people who substitute vaping for cigarette smoking are still addicted to nicotine and may continue to smoke cigarettes on occasion, becoming so-called ‘dual users’. This means that while they may have reduced their exposure to tobacco smoke they haven’t completely removed the risk. Because E-cigarettes perpetuate the dependency on nicotine and psychologically the user hasn’t really ‘quit’ smoking it is easy to backslide to tobacco use or to continue to use it infrequently.

Frank T. Leone and Ivor S. Douglas raised some interesting points in their 2014 article entitled “The Emergence of E-Cigarettes: A Triumph of Wishful Thinking over Science”. They highlight the many “protective design modifications” that have been introduced over the years to make smoking ‘safer’, such as filtered tips, mentholation, low tar and ‘light’ cigarettes. All of which failed to enhance the safety of tobacco products. Their concern is that e-cigarettes are another form of wishful thinking, dressed up as an aid to quit, but actually unlikely to make a significant impact on reducing tobacco use. At worst they believe that e-cigarettes appear to distract smokers away from safe and effective methods for controlling the compulsion to smoke. They believe it is important that the e-cigarette should not itself be a barrier to adoption of other known life-saving alternatives to smoking.

In conclusion, it’s clear to see that the use of e-cigarettes is in relative terms safer than continued use of tobacco. However, there are many challenges associated with using e-cigarette as an alternative and people should certainly not assume that vaping is without risk. If they have other avenues for stopping smoking that don’t use vaping this will always be preferable and steps need to be taken to ensure that e-cigarettes aren’t a barrier to these other methods.

There is also a legitimate concern about the effect on non-smokers who take up vaping both in terms of the risk from e-cigarette use itself and the potential for it to act as a gateway to tobacco smoking. E-cigarette sellers must be discouraged from marketing in ways which could encourage non-smokers to take up vaping otherwise they risk becoming another contributor to the already startling cancer statistics.

So, to answer the question, is vaping safe? In isolation, no it’s not, but compared to cigarettes it is the lesser of two evils. Ideally, we’d be better off without either though.


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