We all know smoking is bad for us. But e-cigarettes, with their futuristic casings and fruity flavours seemed to promise a safer alternative. Unlike smoking cigarettes, vaping doesn’t deliver tar and carbon monoxide deep into the lungs, avoiding the health impacts of smoking’s two most dangerous components. But now the healthiness of e-cigarettes – which deliver nicotine through the inhalation of a heated-up liquid – is being increasingly drawn into question.
The US is currently investigating an inexplicable outbreak of lung disease in scores of teenagers and young adults who have been using e-cigarettes. At least 193 potential cases, including one death, have been reported to the nation’s health protection agency, the Centers for Disease Control and Prevention (CDC), this summer.
In many cases, the patients complained about breathing difficulties or chest pain before being hospitalised. Some were also suffering from vomiting, diarrhea and fatigue. Yet, since the first cases were logged in June, it is still not clear if a specific vaping product might be causing the illness and, as a result, no products have been pulled off the market – although many patients also acknowledged filling up their vape pods with liquids containing cannabis oil. These are increasingly sold in states where medical marijuana is legal.
The American Vaping Association, however, is pointing the finger at a “black market” of tainted THC-containing vape cartridges.
While the cause of these new lung disease cases remains a mystery, we’re also largely in the dark about the long-term health effects of vaping. “If you look at what’s in the vapour of electronic cigarettes, you see a number of things that are likely to cause long-term harm,” says John Britton, professor of epidemiology at the University of Nottingham.
Whilst considered much less harmful than conventional cigarettes, the prolonged use of chemicals used in e-cigarette liquids may increase the risk of chronic obstructive pulmonary disease – a condition that causes breathing difficulties due to narrower airways – lung cancer or cardiovascular disease, he says.
“I think it’s likely that somebody who vapes all his or her life will have a higher incidence of those diseases, but the absolute level of risk increase will be pretty small.” Britton points out that it is impossible to know with certainty until a whole generation of people has gone through life without smoking but using e-cigarettes. In the UK, for instance, most vapers are current or former smokers. A 2019 report from Public Health England found that only 0.2 per cent of under 18-year-olds who have never smoked use e-cigarettes regularly.
Recent research led by Jonathan Griggs, professor of paediatric respiratory and environmental medicine at Queen Mary University of London, suggests vaping may up the risk of pneumonia. His team exposed nose lining cells to e-cigarette vapour and then to pneumococcal bacteria, a pathogen known to cause lung infections.
The bacteria appeared to be more likely to stick to the lab-grown airway cells when exposed to the vapour – an effect that has previously been reported in traditional cigarette smoke or particulate matter from fossil-fuel pollution. “The stickiness is just the first stage of the developing infection,” says Griggs. Bacteria sticking to airway lining cells are able to invade body tissue more easily and result in pneumonia, however, as he points out: “There are many other factors that are at play to make you either get pneumonia or not.”
Griggs’ study adds to the growing body of evidence showing that e-cigarettes and other vaping devices are not completely harmless. Still, in comparison with smoking, vaping appears to be much safer. In 2018, an independent expert review commissioned by Public Health England (PHE) found vaping poses a small fraction of the risks associated with smoking: e-cigarettes are considered at least 95 per cent less harmful and are helping people to successfully quit smoking. It is estimated that up to 57,000 smokers in England ditch cigarettes for a vape pen every year.
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And even though long-term data on e-cigarettes isn’t available, it’s by no means an understudied area, says Linda Bauld. The professor of public health from the University of Edinburgh was one of the experts involved in the PHE report. The risks of smoking have been thoroughly researched over the last 50 years, which has allowed scientists to estimate the possible impacts of e-cigarettes based on the products they contain.
“There’s literally thousands of studies on e-cigarettes underway,” Bauld says, clarifying that it is more challenging to compare different devices and flavours and study their impacts as there are too many on the market – an even greater challenge for unregulated e-liquids containing unknown substances.
The experts we spoke to speculated that the cases reported to the CDC might be the result of poorly-manufactured devices or tainted liquids. “We definitely don’t have much, if any, research on when people modify devices and use them for substances that were not indented to be vaped, which seems to be what’s been happening in the US,” says Bauld, adding that some people even mix their own liquids.
She warns that THC vape juices shouldn’t be used at all as they essentially contain oils. “You shouldn’t be vaping anything that’s an oil deep into your lungs,” she says. “We know from factory workers and occupational exposures what some of the effects of those are and it’s not good.”
Diacetyl, on the other hand, is a butter-flavouring that has been linked to bronchiolitis obliterans (nicknamed “popcorn lung”) over a decade ago after a cluster of US factory workers were found to have the rare lung condition as a result from inhalation of the chemical. Although there is no solid evidence that diacetyl in vape juice is linked to lung disease, in 2016 the EU banned the substance from vaping liquid.
Whatever may have caused the recent death and lung diseases in the US, consumers wanting to quit smoking shouldn’t be put off e-cigarettes and make sure they are buying products from reputable sellers, Bauld says. “They should check the packaging and labelling and make sure it complies with the regime in their country.”
Meanwhile, Griggs is awaiting the results from the CDC’s investigations with interest. “It’s detective work and the CDC is absolutely the right agency to do that,” says Griggs. “They’ve got all the right personnel to really hone down on what the common thread is in between all of these [cases], if there is a common thread.”
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