October 07, 2019
Few topics in public health have sparked as much controversy in the past decade as electronic nicotine delivery systems. Electronic cigarettes (e-cigarettes), the most common ENDS product, first emerged in the U.S. market in 2006 and have steadily gained in popularity. Millions of U.S. adults and youth now use e-cigarettes.
The rapid growth of ENDS has exceeded the rate of scientific discovery, leaving health professionals and the public unsure about the safety of these products and their potential to promote or hinder health.
As a member of The University of Kansas Cancer Center’s Cancer Control & Population Health research program, myself and a team of researchers try to identify better ways to bring cancer control efforts to the communities we serve. Given how quickly e-cigarettes have gained popularity, I want to provide an overview of these products, as well as focus on a group particularly prone to e-cigarette use: adolescents.
What are e-cigarettes and how do they work?
E-cigarettes are battery-operated devices that heat a liquid (called an e-liquid) made up of nicotine, flavoring and additives, mostly propylene glycol and/or glycerin. The wide variety of additives in e-liquid formulations also compounds the difficulty of carrying out well-controlled scientific studies on large populations.
Not all contain nicotine, but most do. A primary difference between how e-cigarettes and conventional cigarettes work is that the nicotine is heated and not burned. The act of puffing heats the e-liquid, which produces an aerosol or vapor that is inhaled. These products are commonly referred to as vape pens and the act of using them is vaping because of the noticeable cloud of vapor that is produced.
Are e-cigarettes safe?
The best evidence to date on e-cigarettes comes from a 2018 report conducted by the National Academies of Sciences, Engineering and Medicine Committee Review of the Health Effects of Electronic Nicotine Delivery Systems. Some of their findings are summarized below.
The amount of nicotine and harmful chemicals (such as formaldehyde) in e-cigarettes varies depending on the product and how it is used. In general, e-cigarettes deliver the same amount of nicotine, but fewer harmful chemicals than traditional cigarettes. If used alone (i.e., not in combination with cigarettes), e-cigarettes are likely to pose less risk to an individual than regular cigarettes.
The long-term health effects of e-cigarettes are not known. This is due to the short time that these products have been on the market and the lack of long-term studies. Because e-cigarettes contain fewer harmful chemicals and the majority of tobacco-related disease and death is due to the harmful chemicals in tobacco, not the nicotine, many assume that electronic cigarettes will have fewer long-term health effects. At this time, there is not enough data available to evaluate this claim.
However, e-cigarettes do have known short-term health effects. They raise heart rates, increase coughing and wheeziness, disrupt cells that line the inside of the heart and blood vessels and promote oxidative stress that might lead to tissue damage.
E-cigarettes and youth
According to a 2014 Centers for Disease Control and Prevention study, nearly 69% of middle and high school students – more than 18 million children – see e-cigarette ads. The advertising has been effective: e-cigarette use increased an astounding 900% among high school students from 2011 to 2015.
One product in particular, Juul, is widely popular among U.S. youth. Ask any high school student you know and it is likely they have heard of Juul and know at least one person who uses Juul.
A Juul resembles an easy-to-disguise thumb-drive, plugs into a computer to recharge and is filled with a pod containing nicotine salts (a more effective way of delivering nicotine than e-liquids) that come in an array of sweet flavors that appeal to youth, including bubblegum, mango, mint and crème brûlée . They are small enough to fit into a closed hand.
All Juul pods contain nicotine and at a concentration that is higher than other e-liquid nicotine concentrations (5% versus 2.4%). The manufacturer claims each Juul cartridge of nicotine liquid contains as much nicotine as a pack of cigarettes – about 200 puffs.
Juuling has become so popular that the Food and Drug Administration has begun an aggressive campaign to curb sales to youth.
The primary concern with e-cigarettes among youth is that they are introducing nonsmoking youth to the behavior of smoking, renormalizing smoking and reversing decades of progress in tobacco control. Youth who have never smoked traditional cigarettes are trying e-cigarettes. Never-smoking youth and young adults who use e-cigarettes are more likely to try conventional cigarettes. It is unclear if youth who use e-cigarettes go on to become regular cigarette users, but experimentation is an established risk factor for smoking in adulthood.
An additional concern about e-cigarettes in youth is exposure to nicotine. A 2016 Surgeon General’s report concluded that any exposure to nicotine in youth is unsafe, can cause addiction and can harm the developing adolescent brain.
Stopping the surge
For a long time now, we have known that traditional cigarettes are bad for health. E-cigarettes likely pose less risk to an individual than traditional cigarettes – however, their long-term health effects for diseases like cancer are not yet known. As the only National Cancer Institute-designated cancer center in the region, we hold ourselves accountable to educate and inform our communities about habits that have the potential to put people at greater risk for cancer.
So, what is the right approach to reducing this alarming trend among youth and young adults? Both NASEM and the American Cancer Society recommend that healthcare professionals put screening and counseling measures in place to prevent youth and young adults from ever trying e-cigarettes and other nicotine-containing tobacco products.
- Routine pediatric care should include questions that screen for nicotine and tobacco use, including e-cigarettes.
- Youth should be counseled about the dangers of nicotine and advised to stay away from all tobacco products, including e-cigarettes.
- Youth who are experimenters or regular users should be counseled to stop.
Given the lack of long-term data on e-cigarettes and their surge in popularity in youth, we should do the best we can to prevent adolescents’ use of these products.