Welcome to the eCig generation. Vaping is quickly becoming the new smoking among teenagers and as a doctor I am highly concerned. According to the latest National Youth Tobacco Survey released by the Centers for Disease Control this week, e-cigarette use among middle and high school students tripled in 2014. Proponents of e-cigarettes argue that the survey result which showed traditional cigarette use declined among teenagers is getting less attention. While that is certainly a positive step forward, that doesn’t lessen my concern around e-cigarettes.
Are e-cigarettes creating the next generation of nicotine-addicts? Does vaping inevitably lead to conventional cigarette use?
The fact is vaping has risen fast among teenagers and parents need to be aware of what we both know and don’t know about its threats to our health. While e-cigarettes may in some cases help smokers kick the habit, usually by a gradual reduction of the amount of nicotine in each cartridge, it also appears to potentially attract new users, most of which are teenagers who have never smoked. The risk of creating a new problem while solving an old one is a major reason the FDA questions whether to approve widespread e-cigarette use.
Here are a few numbers to consider:
- 4 million people in America currently use e-cigarettes according to The Tobacco Vapor Electronic Cigarette Association
- Of those, 1.8 million young people have tried e-cigarettes according to the Centers for Disease Control
- 160,000 students out of grades 6-12 tried e-cigarettes in 2014 (but never have smoked conventional cigarettes)
- E-cigarettes are a $1.5 billion dollar industry and that’s just in the United States
- More than 250 e-cigarette brands are available in the U.S.
As of 2015, e-cigarettes became legal for minors to buy in 10 states including Maine, Massachusetts, Texas, and Pennsylvania. More than 16 million minors aged 17 and under live in these states in the U.S.
The profit numbers are also particularly astounding considering e-cigarettes gained popularity only in 2007, a mere 8 years ago. I can’t help but believe there is a correlation to an increased use among young people and this newly billion-dollar industry.
But enough said about that.
Lack of Research Around E-Cigarettes
Research is essential for us to understand the risks of inhaling the liquid vapor, synthetic nicotine and propylene glycol (PEG) –some of the main components found in e-cigarettes– over a long period of time.
It’s not the medical data that is as disturbing but the lack thereof. There have been studies evaluating their safety and the FDA has performed numerous testing around the chemicals but almost no clinical trials have been performed to determine long or short-term health effects.
To deem e-cigarettes "safe" because they contain fewer toxins than typical cigarettes is troubling. The data is disturbingly incomplete for an entirely new product that has been FDA approved. The fact is e-cigarettes haven't been fully studied.
As a doctor, the supposed positives e-cigarettes have on aiding heavy smokers to quit doesn't change my concerns on how easily accessible these products are to young people and the potential addictive behavior they can ensue.
When someone stops inhaling the tar of cigarettes and only inhales nicotine, what does that do to your body? Again we don't know. These products must undergo much more testing in order for the medical community to fully understand the long-term health risks of inhaling synthetic nicotine and propylene glycol (PEG), some of the main chemicals found in e-cigarettes.
Again, my main concern is accessibility to teenagers. The potential health risks of a young person being exposed to the known and unknown chemicals in e-cigarettes is troubling.
What's in e-cigarettes?
We know e-cigarettes contain some form of synthetic nicotine released by a vaporizer, but levels consistently vary across products. A battery-powered heater then releases propylene glycol (PEG) which is the chemical used to make fake smoke, often for theatrical use.
Now of course when compared side by side to conventional cigarettes, that contain tar, 43 known carcinogens, carbon monoxide, ammonia and others, e-cigarettes can seem perfectly safe.
But don't be misled.
Remember, there is still a lot of unknown information about the long-term health effects from vaping.
Health concerns expressed by many medical experts include the fact that there have been no long-range studies of e-cigarettes’ impact on users, nor of synthetic nicotine vapor inhaled directly into the lung tissue as well as PEG’s effect.
Liquid nicotine is extracted from tobacco and it can be lethal when ingested or absorbed through the skin. Of course we don't know the long-term effects of inhaling small amounts while vaping, but a dose less than one tablespoon is enough to kill an adult if ingested or absorbed. What's more, one dose or less than one teaspoon can kill a child. In fact, officials identified that between September 2010 and February 2014 poison control centers received 215 calls per month, up from 1 call per month, regarding e-cigarette nicotine-infused liquid incidents. This time at which this increase began was just as e-cigarettes gained popularity and FDA approval, just around the corner.
Liquid nicotine or the "vapor" in e-cigarettes contains ultra fine particles, with tiny amounts of toxicants and even some heavy metals. And again, we don't know the specifics of these toxins, as companies are currently not disclosing all of them. I'll explain more about that later.
E-Cigarettes a Gateway to Tobacco Cigarettes?
For young people, it's quite easy to acclimate to vaping. As opposed to conventional smoking where dizziness, coughing and learning to inhale can take some time for new smokers, anyone vaping for the first time can inhale on the first puff. And there's little to no odor.
This ease of use also worries me.
Furthermore, e-cigarettes are packaged to appeal to young people. The high-tech design, accessibility and assortment of flavors like chocolate, strawberry, bubble gum and cherry feed into this sensation-seeking behavior and the lifestyle appeal young people may be looking for. Along with rumors of little to no risk, most teenagers are under the impression that vaping is a perfectly safe alternative to smoking regular cigarettes. And we can't ignore the obvious factor of peer influence.
Now the big question is are e-cigarettes a gateway product to real tobacco products? Will young people start with vaping only to graduate to smoking conventional cigarettes?
The fact is nicotine is an addictive agent and exposure at a young age may cause lasting harm to the brain, since it is still developing in those years. It also promotes addiction which could lead to sustained tobacco use.
Just as second-hand smoking is a major concern, the effects of second-hand vapor are also unknown but of major concern.
Proponents of e-cigarettes claim they are diverting young people away from regular cigarettes, but at what cost?
Both the CDC and FDA need to weigh in on this debate and many more clinical studies are required to understand the habit-forming effects of e-cigarettes.
We know how difficult it is for traditional smokers to escape their nicotine addiction. What type of effect is this having on young people with a vaping habit?
FDA Regulation on E-Cigarettes
Even though e-cigarettes became popular in 2007, the FDA only started regulating them closely in 2011 and there are continuing initiatives around specific issues, starting with the manufacture and sales of these products.
It was only in mid 2014 that serious regulation from the FDA came down on manufacturers around the disclosure of the chemicals.
But they still have work to do.
One of the major concerns is the considerable variability between the actual contents of the vaporizers across various e-cigarette brands. Just because e-cigarettes contain fewer toxic substances than cigarette smoke, doesn't mean they're not a health threat.
Secondly, the actually amounts of synthetic nicotine levels on the labels may not match the actual amount in the cartridge. FDA testing showed levels ranged from 26.8 to 43.2 micrograms nicotine per 100 millimeter puff, even from the same e-cigarette brand.
The FDA claims there is strict regulation in place to protect minors but clearly with this recent survey released by the CDC showing use has tripled among 6-12th graders, the regulation isn’t strict enough. And it certainly doesn't help that over 10 states approved the sale of them to those who are 17 and under.
E-cigarette companies promise sophisticated age-verification technology limits access to minors. Well I visited BluCigs.com (an e-cigarette company) to see for myself. What I found was a very simple pop up, and with one click, I was in. I have a hard time believing our tech savvy teens couldn’t figure that out.
E-Cigs are Easily Accessible Online
Online accessibility is a huge issue but beyond that is quality control. Many companies are not disclosing all the ingredients in their product aside from what the FDA regulates. Back in 2009, the FDA found a liquid nicotine that carried about 1% diethylene glycol (DEG) —a toxic chemical ingredient found in antifreeze. There is also a considerable lack in health and safety claims on e-cigarette product labels.
The American Lung Association has called for a ban on e-cigarettes. Researchers have found, despite marketing claims that e-cigarettes are safer than smoking tobacco, users experienced diminished lung function, airway resistance and cellular changes along with signs of inflammation.
What Parents Need to Know About E-Cigarettes
As both a parent and a doctor, I am highly concerned about the effects e-cigarettes are having on our younger generations. Here is what I recommend to parents out there:
1. Understand that any level of nicotine inhaled at a young age can affect brain development
2. Candy flavors increase the appeal to teenagers
3. There is almost no smell, which makes them very hard to detect or find
4. Educate your kids on the health risks of e-cigarettes, emphasizing the unknown factors that may affect their health