By Dr. Vivek Sinha
It hit the U.S. Markets in 2006 and since then, it has been steadily rising in popularity for both adults and adolescents. It has been featured in numerous media outlets. Public health concerns have been raised asking for tighter regulations around this product. It is so concerning that the U.S. Surgeon General has referred to it as an “epidemic among youth.” What is this product? We are talking about electronic cigarettes.
According to the Surgeon General’s Advisory on E-Cigarette Use Among Youth, “Since 2014, they have been the most commonly used tobacco product among U.S. youth.” When it comes to the pediatric and adolescent population, most primary care physician’s opinions are in-line with the Surgeon General — simply stated, kids and adolescents should not use e-cigarettes.
In speaking to adults, I am often asked to weigh in on e-cigarettes and their possible assistance with smoking cessation versus their potential risks. This is more of a one-on-one conversation that should take place between the adult patient and his or her primary care physician. The purpose of this article is to give invested parents and adults a “crash course” about e-cigarettes and to discuss potential health effects.
The best way to start is to learn about the product itself. E-cigarettes are battery-operated devices that heat a liquid which produces a vapor that the user inhales. The vapor usually contains nicotine but is not tobacco smoke. They were originally designed to look like conventional cigarettes but over time they have evolved.
The first generation of e-cigarettes were designed to look and feel like a conventional cigarette. These devices were not rechargeable or refillable. The second and third generation of e-cigarettes were larger than conventional cigarettes and allowed the user to customize their device. These featured rechargeable batteries and refillable cartridges. The fourth generation of devices are also known as “pod-mod devices” which have recently exploded in popularity. A popular brand called JUUL is shaped like a small USB flash drive. Their atypical appearance and small size can make it easy to go unnoticed in a school setting.
Depending on the brand, e-cigarette liquid components can have different ingredients. They usually contain ingredients like nicotine and can often have flavoring. The flavoring is often geared towards tastes that might be attractive to a younger audience, such as mint, strawberry lemonade or grape.
Much of the controversy and discussion about e-cigarettes focuses on possible adverse health effects. While there is currently no observational data about long term affects just yet, there are three types of possible adverse effects that are being observed: nicotine exposure, aerosol exposure and risks of the device itself.
The amount of nicotine that one can obtain from a device can vary. Variables such as vaping technique, puffing intensity, the concentration of nicotine in the cartridge and user experience can all play a role. The more experienced a user is, the more nicotine they can often extract from a device. Nicotine’s well-documented affects can include increased heart rate and blood pressure, lightheadedness and breathing issues.
Aerosol risks of vaping are still being studied. Vaping does not expose the user to toxins like tars and carbon monoxide like cigarette smoking does. However, in 2019 the Center for Disease Control has reported more than 1,000 cases of severe lung illness linked to the use of e-cigarette vapors. The most common symptoms included shortness of breath, cough and chest pain. Some symptoms were severe enough for patients to be placed on ventilators. The exact cause of these severe illnesses is still unknown and are actively being studied.
A less common, but very real concern about e-cigarettes comes from the device itself. Burns and chemical injuries have been reported. The nicotine vial itself can contain a large concentration of nicotine that must be kept safe from small children to avoid accidental nicotine poisoning. The lethal dose of nicotine for children is approximately 10 mg and a typical 5 ml vial refill can contain up to approximately 100 mg of nicotine.
Among adults, one issue that fosters discussion is the role of e-cigarettes in smoking cessation. Since the vaping/aerosol components do not contain many of the toxic substances found in typical cigarettes, there has been some evidence to suggest that e-cigarettes may play a role in assisting adults in stopping smoking, however more data is needed when comparing e-cigarettes to other FDA-approved smoking cessation medications. The concern in using e-cigarettes currently lies with the fact that there have been numerous instances of severe lung injury and the role of using these devices as an aid to stop smoking versus other safer methods of smoking cessation must be carefully weighed against their potential risks.
The biggest concern with e-cigarettes lies in the rapid increase in use we have seen in our adolescent population. Among youth, using e-cigarettes may be thought of as being safer than smoking, however the risks of nicotine exposure in children is very real. Nicotine can affect the developing brain — and we know that brain development continues until a person reaches their mid-20s.
According to the Surgeon General’s report, e-cigarettes have the potential to not only “normalize” smoking behavior but to also act as a gateway for adolescents to start smoking typical cigarettes, which has extremely well-documented cardiovascular effects. The report continues to advise that e-cigarettes can also be used as a delivery device for other drugs and “in 2016, onethird of U.S. middle and high school students who ever used e-cigarettes had used marijuana in e-cigarettes.”
Guiding adolescents and children towards making healthy choices is critically important. Like most things in health care, it starts with a knowledge. If you are a parent, learn about the different types of devices, learn about their potential risks to the developing brain and have a conversation with your child. Be informed about the school’s policies and practices about keeping a tobacco free environment and use your child’s primary care physician to address any medical concerns. Most importantly, lead by example. If you smoke, it is never too late to quit.
The writer is the chief medical officer of Belleview Medical Partners, an office and house call practice based in Old Town.