By Whitney L.J. Howell
When e-cigarettes hit the market in 2007, they were embraced as an effective and safe strategy for smokers to break their addiction to traditional cigarettes. Since then, they’ve grown in popularity among all age groups. But research has revealed mixed success in helping to quit.
And now North Carolina researcher are questioning their safety.
A new study from Research Triangle Park-based RTI International points to many e-cigarette characteristics that could pose intrinsic, and yet unidentified, health dangers. The research comes on the heels of reports that e-cigarette use is on the rise.
In North Carolina, according to the North Carolina Youth Tobacco Study, e-cigarette use sky-rocketed 325 percent among high school students from 2011 to 2013. A full 10 percent of students are now considering using e-cigarettes.
Other research, including a March 2014 Journal of the American Medical Association Internal Medicine study, showed e-cigarette use among Americans leaped from 2 percent of U.S. smokers in 2010 to more than 30 percent in 2012.
Whether e-cigarettes are helping smokers quit has been the subject of pretty fierce debate in the research world. A May 2014 study published in Addiction showed the alternative cigarettes helped 60 percent of aspiring quitters reach their goal. Other studies suggest that e-cigarette users quit smoking but keep using the e-cigarette as a way to get nicotine.
Many of those former cigarette smokers argue the newer devices are safer.
But to date, said Jonathan Thornburg, RTI’s director of exposure and aerosol technology and lead study author, there’s been no way to prove e-cigarettes are any safer than traditional cigarettes. And, it turns out, he said, they may be just as dangerous.
“The visible smoke from e-cigarettes dissipates just after exhale, but those particles are still there – there’s still a high potential that the public will breathe them in,” Thornburg said. “Other research has found that second-hand nicotine exposure from e-cigarettes is similar to that of conventional cigarettes.”
Traditional cigarette use is falling among American high school students, but, based on Centers for Disease Control and Prevention data, e-cigarettes are the popular substitute. An April CDC report, based on the National Youth Tobacco Survey, revealed e-cigarette use has tripled among American teenagers.
From 2011 to 2014, e-cigarette use nationwide among middle-schoolers rose from 1.1 percent to 3.9 percent and from 4.5 percent to 13.4 percent among high-schoolers. Those rates translate to approximately 450,000 middle school students and 2 million high school students.
Although the Food and Drug Administration has deemed many e-cigarette ingredients safe for consumption, that categorization doesn’t necessarily mean they’re safe to inhale. That’s where the safety of e-cigarettes becomes ambiguous, Thornburg said.
E-cigarette vapor particles are small – only slightly larger than a bacteria, at a width of 100 to 800 nanometers. But, even at that size, they pose a threat, he said. Nearly half of all inhaled e-cigarette particles remain in the lungs to grow in the respiratory system, and the remaining exhaled particles can be as dangerous as second-hand smoke.
“People need to know the potential for significant second-hand smoke with e-cigarette vapors,” Thornburg said. “Danger doesn’t just come from inhaling the nicotine, but from the other chemical vapors too.”
Lighting an e-cigarette also presents a risk. E-cigarettes don’t ignite like traditional ones, so there’s no carcinogen from combustion, but starting one produces a slightly altered form of formaldehyde, a disinfectant and embalming fluid. That form has a greater potential for getting stuck in lung tissue.
In addition, little is understood about what happens when other e-cigarette ingredients get into lungs. The glycerin, propylene glycol (a syrupy liquid added to food, cosmetics and some medicines to help them absorb water and stay moist), food preservatives and artificial flavorings could be dangerous to breathe in.
In fact, it’s already well known, Thornburg said, that inhaling artificial butter flavoring, one of the popular flavors in the liquid used in e-cigarettes, is dangerous.
He said that while there could be a level of preservatives and flavors that’s safe to breathe in, “we don’t know what that is yet.”
To answer that question, Thornburg’s team is conducting a study to determine if e-cigarette second-hand exposure to the nicotine and other ingredients is high enough to warrant concern. The goal is to inform public policy on how and when e-cigarettes should be regulated.
But until that data exists, he said, cities and towns can’t create any ordinances addressing e-cigarette use.
Determining the actual health risks associated with e-cigarettes goes beyond giving teeth to public health regulations. It’s also critical to combating advertising and marketing efforts that present these products as completely safe alternatives to traditional cigarettes, said Annice Kim, a social scientist in RTI’s public health policy research program.
From 2011 to 2014, money spent on publicizing e-cigarettes ballooned from $6.4 million to more than $100 million, reaching approximately 24 million youths.
“It’s a big public health concern because these ads might make e-cigarettes appealing to young people,” Kim said. “It’s alarming from a social, medicine and public-science perspective that these ads feature celebrities espousing the benefits of e-cigarettes when their safety has not been established.”
Despite heavy advertising and lack of safety data, some states are already implementing measures to curb e-cigarette use. In most states, including North Carolina, e-cigarettes cannot be sold to anyone under age 18. North Carolina also taxes the sale of e-cigarettes.
Other states have implemented e-cigarette bans on school property, and several states, also including North Carolina, specifically prohibit the use of e-cigarettes in 100 percent smoke-free sites.
Alongside the RTI study, research is starting to reveal that e-cigarettes carry their own health hazards. A recent study out of UNC-Chapel Hill showed that five of 13 liquid flavors – including hot cinnamon candies, banana pudding and menthol tobacco – are toxic in high doses and can change cell life, cell reproduction and cell communication in the lungs.
Work out of the University of Alabama School of Medicine discovered that the temperature of the e-cigarette coil is directly associated with the production of harmful chemicals, such as acrolein (used in herbicides), acetaldehyde (a toxic irritant) and formaldehyde. And inhaling the vapor suppresses one’s ability to cough.
Albert Einstein University researchers found that after 30 e-cigarette puffs in 15 minutes, users were far less sensitive to capsaicin, a component of chili peppers that can induce coughing. A reduced ability to cough can be dangerous because coughing can prevent choking and it removes infectious agents from the lungs.
New research with mice from Indiana University found that just the nicotine in e-cigarettes is enough to negatively impact lung function. The effects are greater with higher doses, but nicotine inhalation causes acute lung inflammation, decreased lung cell growth and a change in lungs’ ability to act as a barrier to outside insult.
Even substances found in nicotine-free e-cigarettes attacked the molecules that hold together the endothelial cells that line the lungs and protect from infection.
The hope, Kim said, is this current and future research will continue to highlight the yet-unknown dangers of e-cigarettes both to the user and those in the vicinity. Data that reveals the potential negative impacts, she said, could be the best arrow in the quiver to fight against marketing efforts that support e-cigarette use.
“If we don’t make an effort to educate people, we’re only going to be flooded by counter messages that e-cigarettes are perfectly safe,” Kim said. “Perceptions, correct or not, will be spread by word of mouth and on social media.”