Domingo Solomon, PA-C, Taylor Made Diagnostics
In 2003, the electronic nicotine delivery systems (ENDS) or more popularly termed "electronic cigarettes" was developed in China and introduced to the United States in 2007. Since its introduction, the e-cigarette market has expanded to 500+ brands and 7,700 flavors. The FDA defines e-cigarettes as a device that aerosolizes liquid (e-liquid or “juice”) into an inhalable vapor. E-cigarettes often use a battery-operated heating element (atomizer) to aerosolize the e-liquid. The e-liquid is contained in either a cartridge (cartomizer) or a tank. Other names of ENDS are E-pens, E-pipes, E-hookah, E-cigars or most popularly, vapes.
E-liquid is comprised of several compounds, which are seen as major safety concerns. Nicotine, the major substance responsible for addiction to e-cigarettes and traditional tobacco products, is a naturally occurring toxic substance. It can be absorbed through the skin or eyes, inhaled or ingested. In large doses, nicotine can cause nausea and vomiting; this can progress to respiratory failure, seizures, and even death. The U.S. Surgeon General recognizes that nicotine is a hazardous substance in multiple ways. Nicotine hinders the developing brain in adolescents and young adults; cognitive and behavioral abilities lack compared to non-nicotine users. Nicotine used during pregnancy has been shown to result in preterm, lower birth weight, poor development in the lungs and brain of the baby. Stillborn rates are higher in women who smoke.
The e-liquid’s base, which is typically propylene glycol, acts as a solvent to mix nicotine, flavoring, coloring and other chemicals. Propylene glycol is found in certain medicines, cosmetics and food products and is also used to create artificial smoke/fog. It serves as a base product in antifreeze as well, but is safer than its cousin compound ethylene glycol.
There are a variety of flavors that may attract teenagers and adult non-smokers to start ‘‘vaping.’’ Flavoring may be composed of harmful compounds. In 2015, National Institute of Health (NIH) reported finding one such flavoring additive, diacetyl, which has been associated with a non-reversible lung condition, "popcorn lung." Diacetyl is a buttery-flavored additive used in microwavable popcorn. Prolonged inhalation of the compound causes scarring to the smallest air passages of the lungs called bronchioles. This results in a blockage of oxygen in the lungs. Another flavoring additive used in e-cigarettes is 2,3-pentanedione which is structurally similar to diacetyl. The National Institute of Occupations Safety and Health (NIOSH) established that 2,3-pentanedione causes lung scarring in animal studies. NIOSH has set occupational exposure limits for diacetyl and 2,3-pentanedione due to their toxicity.
E-cigarettes do not produce smoke, tar, carbon monoxide, arsenic, or vinyl chloride like conventional cigarettes, but these devices still produce emissions which result in secondhand exposure. A few studies revealed that e-cigarettes emit detectable levels of carcinogens such as formaldehyde, acetaldehyde, benzene and nitrosamines. There is no current evidence suggesting secondhand emissions are safe.
As of now, there are no regulations from the U.S. Food and Drug Administration (FDA) regarding to the chemicals used to make the e-liquid or the concentrations of the chemicals (including nicotine amounts). Essentially, no safety agency monitors what is and is not allowed in the e-cigarette; however, the FDA does regulate the marketing and packaging of traditional cigarettes and other tobacco products. Vaping is different because the e-fluid does not contain tobacco.
All e-cigarettes are not alike, nor are the e-liquids. FDA lab studies investigated cartridges that were labeled as nicotine-free; their studies revealed otherwise, as traceable levels of the nicotine were found. Further studies have found an inconsistency of the nicotine concentration delivered by the e-cigarette of the same brand and strength. Lastly, it was found that e-cigarettes utilizing higher voltage were capable of delivering higher concentrations of nicotine.
Although many smokers utilize the e-cigarette to replace the traditional tobacco cigarette, ENDS are currently not approved by the FDA as a means to smoking cessation; however, the U.S. Public Health Service reports there are seven FDA approved therapies that have been seen as most effective with smoking cessation, when in combination with individual, group or phone cessation counseling. Quit Now Virginia is a free resource and counseling service that is provided to Virginia residents to assist those trying to cease using traditional tobacco products as well as ENDS. 1-800-QUIT-NOW (1-800-784-8669).
Overall, the e-cigarette is still relatively new. The latest studies have identified many hazardous substances in the e-cigarette emissions, but these appear to be at much lower concentrations than that of traditional cigarettes. It can be said that e-cigarette emissions are not as safe as clean air, nor does existing research conclude that e-cigarettes are absolutely safe. Overall long-term effects of vaping are yet to be determined.
Please stay tuned for more about e-cigarettes.
About the Author
Domingo Solomon, PA-C is an occupational medicine provider with Taylor Made Diagnostics, an occupational medicine and workers compensation clinic, located in in Chesapeake, VA. Taylor Made Diagnostics has been an active member and supporter of VSRA for 10+ years.
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