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Most people who smoke wish they didn’t.   Odd, isn’t it?   Spending all that money on a product that often annoys those around you, that forces you to stand outside your place of work on a cold, wet day, wasting break-time, and that wrecks your health when you’d really rather you didn’t do it at all.   Almost seven out of every ten smokers would like to give up the habit, according to Doctor Michael Blaha, a preventive cardiologist and director of clinical research at the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease in the United States.   But of course, it’s not just a habit, it’s an addiction; nicotine is an addictive drug, like heroin and cocaine, so giving up smoking isn’t easy.   I know from bitter experience: I was a heavy smoker (30 to 40 a day) for more than twenty years and parting myself from tobacco was difficult.  It was more than thirty years ago but I remember it vividly.  I was running a radio newsroom at the time and some of my staff wished I would take it up again, simply to improve my temper.   But I persevered and I’m very, very glad I did.   I had an economics lecturer once who still had nightmares in which he accepted a cigarette at a party, despite having given up smoking twenty-five years earlier.    I have been fortunate in not suffering the same fate and I now find I dislike intensely the smell of burning tobacco, even crossing a street to avoid walking behind a smoker.   Or a vaper.

And that’s where there are strong differences of scientific and medical opinion on either side of the Atlantic.   In the United States, the Trump administration and a number of individual states are considering a ban on flavoured vaping liquids.   The opinion of some experts there seems to be that they encourage young people to take up smoking (or at least vaping) and that they are, like regular cigarettes, dangerous.   Perhaps we should pause here to look more carefully at exactly what e-cigarettes are.   They come in various forms.   There are “cigalikes”, which look similar to normal cigarettes and can be either disposable or rechargeable.   There are “vape pens”, which comprise a small tube, a storage tank for “e-liquids”, replaceable heating coils and rechargeable batteries.   Pod systems are small rechargeable devices with e-liquid capsules.  And “Mods” come in a variety of shapes and sizes but are usually larger than the other devices, complete with a refillable tank, longer-lasting batteries and adjustable power.   Turning up the power can increase the heat which gives a stronger “hit”.  The liquids can come in a variety of flavours, often fruit flavours, and virtually all contain (or are supposed to contain) nicotine.   The devices do not burn tobacco, nor produce tar nor carbon monoxide.   Instead, they heat the chosen liquid which contains nicotine but also other chemicals and flavourings.

In fact, most e-liquids can contain a wide variety of substances apart from nicotine, such as diacetyl – a flavouring also found in popcorn – along with acetoin and anatabine.  Another ingredient, acrolein, for instance, is the simplest unsaturated aldehyde, a colourless liquid with a piercing acrid smell.   If you overheat cooking fat you get the same smell because the glycerol in the burning fat breaks down into acrolein.   There are various forms of nicotine by-products too, such as n-nitrosonornicotine, produced during the curing and processing of tobacco and a known carcinogen, and its precursor, nornicotine.  The liquids often contain ethyl maltol, too, which is a sweetener, and 2,3,5-trimethylpyrazine, which occurs naturally in cereals and cereal products such as bread but also in chocolate, baked potatoes, asparagus, Swiss cheese (why only Swiss cheese?   I’ve no idea), coffee, black tea and roasted filberts.   Vaping e-liquids, I should point out, does not contribute to the five vegetables a day you’re expected to consume as part of a healthy diet.   Indeed, the only healthy thing about e-cigarettes and vaping is that most (but by no means all) medical authorities reckon it’s preferable to ordinary cigarettes and that it can help smokers to quit.   That’s why Europeans regard the Trump administration’s suggested ban on e-liquid flavourings as bizarre, as long as tobacco vendors’ shelves are still full of what the Victorians called (somewhat appropriately) “gaspers” – ordinary cigarettes.

LOSING ITS FLAVOUR?

Even so, while UK medical authorities encourage smokers to switch to vaping, in America there are serious safety concerns.   Some experts there claim that young people are taking up vaping despite never having smoked a cigarette because it’s “cool” (a word that advertisers use to use to promote menthol cigarettes; “cool as a mountain stream” is one I remember from way back when).  In the United States there have been some serious health issues – including deaths and hundreds of hospitalisations – related to vaping, although they’re problems that would not have arisen in Europe under existing European Union regulations.   Doctor Alok Patel, a New York paediatrician, has reminded patients that nicotine is highly addictive and “detrimental to the developing adolescent brain”, a process which continues until the mid-20s, and it’s a point much stressed by the pro-ban lobby.   Doctor Patel believes a ban on flavourings would limit vaping’s appeal, at least to the young.   However, the US Centre for Disease Control have released figures showing that 63% of deaths were linked to the use of THC, the psychoactive substance found in cannabis, not nicotine, that was contained in black market e-liquids.   There has also been a high incidence of lung injuries – more than 1,600 by late October, mostly among young white men.   Older people of 65 or over made up just 2% of the illnesses linked to vaping but accounted for 25% of the deaths.   It’s worth bearing in mind, however, that most of those were people who had smoked ordinary cigarettes throughout their lives and were using e-cigarettes to help wean them off the real thing.   Their deaths, though tragic, may not have come as a surprise to their friends and families.

FDA safety advice on vaping © FDA

Earlier in October, Juul, a manufacturer of vaping products, announced that it would suspend sales of its fruit-flavoured e-cigarettes and e-liquid.   But Juul is just one company and it had already come under pressure after a former executive accused it of knowingly shipping out to retailers a million e-cigarette pods it knew to be contaminated.   Juul’s former senior vice-president of global finance, Siddharth Breja, has filed a lawsuit against the company over the allegation.   He was sacked one week later, in what he claims was retaliation.   In his legal action, Breja claims that executives were told in March 2019 that a quarter of a million Juul mint e-liquid refill kits that were known to be contaminated were shipped out for sale anyway.   Breja claims Juul refused to issue a product recall notice or to issue a health warning.   Former Chief Finance Officer for Juul Tim Danaher said the move would have cost the company billions of dollars and “questioned his (Breja’s) financial acumen” for suggesting it.   As usual with the tobacco industry, profits seem to rate a far higher priority than public health.   A former member of the European Union press lobby who went to work for a US-owned multinational tobacco company was always concerned about what she was doing.  She was also a smoker.  I met her some years ago when she returned to Brussels to celebrate the 30th work anniversary of another journalist, a mutual friend.   “How are you doing?” I asked.   “OK, thanks,” she replied, “still killing millions.”   I won’t name her but she was a good journalist and deserved better.

As for Breja, his lawyer, Harmeet Dhillon, told BuzzFeed News “Mr. Breja became aware of very concerning actions at the company, and he performed his duty to shareholders and to the Board by reporting these issues internally.   In exchange for doing that, he was inappropriately terminated.”   Dhillon added: “This is very concerning, particularly since some of the issues he raised concerned matters of public safety.”   Breja had also urged Juul to add a “best before” date to its packaging, but his idea was ignored.   Former Juul Chief Executive Kevin Burns, who has since been replaced, is alleged to have said in response to the idea: “Half our customers are drunk and vaping like mo-fos (your guess is as good as mine as to the precise meaning, although I suspect it’s somewhat vulgar), who the f*ck is going to notice the quality of our pods?”   Nice to see corporate concern for customers still looming so large.  Mind you, Juul has its problems, having come in for some serious criticism for campaign tactics said to make its products more appealing to the young.   Both the Federal Trade Commission and the US Food and Drug Administration accuse it of undermining efforts to discourage teenage non-smokers from taking up vaping.

It’s all so different on the other side of the Atlantic.   It was back in 2014 that the European Commission proposed laying down rules for electronic cigarettes sold as consumer products in the EU, and they’re very strict.    Adopted in 2016, the rules aim to make the product as safe as possible for consumers, as explained in the Commission’s official announcement: “The Directive sets a maximum nicotine concentration and volume for cartridges, tanks and nicotine liquid containers. E-cigarettes should be child-resistant and tamper evident (it should be clear to see if they’ve been tampered with) and have a mechanism that allows refilling without spillage to protect consumers. E-cigarette ingredients must be of high purity and e-cigarettes should deliver the same amount of nicotine when puffed at the same strength and duration.”  In addition, health warnings must be clearly displayed on packaging, pointing out that the products contain nicotine, giving the amount of nicotine in the product and with an explanatory leaflet enclosed providing information on possible adverse effects, addictiveness and toxicity, with a warning about groups who could be  especially at risk.   The Directive includes monitoring and reporting requirements for manufacturers and importers and imposes a ban on cross-border advertising and promotion of vaping products.

CHEMICAL SOUP

So, while cases of respiratory problems, fatigue, vomiting and diarrhoea have afflicted mainly young and previously healthy people in the United States, that has not been the experience in Europe.   In a report on the use of e-cigarettes in February, 2019, Public Health England wrote that “smoking remains the leading preventable cause of illness and premature death and is one of the largest causes of health inequalities. So alternative nicotine delivery systems, such as electronic cigarettes or e-cigarettes, could play a major role in improving public health.”   Compare that with this report from the US Academies of Sciences, Engineering and Medicine: “There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated.”   It continues that “there is conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances,” and “There is conclusive evidence that other than nicotine, the number, quantity, and characteristics of potentially toxic substances emitted from e-cigarettes are highly variable and depend on product characteristics (including device and e-liquid characteristics) and how the device is operated.”   What is a smoker who wants to quit to believe?   In California, the Department of Public Health has gone further, urging “everyone to refrain from vaping, no matter the substance or source, until current investigations are complete”.   In a statement, Dr Charity Dean, California’s acting public health officer, said “There are numerous unknown factors at this time, and due to the uncertainty of the exact cause, it is our recommendation that consumers refrain from vaping until the investigation has concluded.”  Presumably they’ll just go on smoking those perfectly healthy old-fashioned cigarettes instead?

In research carried out for Public Health England, meanwhile, it was found that vaping is 95% less harmful than traditional cigarettes and that it was helping some 20,000 people a year to give up smoking.   It was also concerned that a lot of smokers – more than 50% – believed vaping to be as harmful as smoking, which it is not.    So why the different attitudes?   It really comes down to regulations and advertising.   America has seen some manufacturers of vaping devices and liquids engaging in a competitive raising of nicotine levels in their products to appeal to heavy smokers.   Europe imposes a strength limit.   Additionally, the EU has a total ban on the advertising of, or sponsorship by, producers of smoking products of any kind, except in internal specialised magazines available only within the tobacco industry.  

According to the American Vaping Association, a lobby group in the United States, most of the deaths and illnesses reported there stem from the purchase of unregulated and badly manufactured vaping devices and liquids from street vendors or other illegal sources.   The New York State Department of Health has reported that laboratory test results showed “very high levels of vitamin E acetate in nearly all cannabis-containing samples” tested.  For every patient who submitted a sample of the product they had been using, at least one contained vitamin E acetate, which is normally used as a thickening agent but which has been used by unlicensed back-street manufacturers to dilute THC oils that are too viscous to vape properly.   Also known as tocopherol acetate, it’s often used in dermatological products like skin creams and topical medication.   Not being oxidised, it can penetrate through the skin to the living cells, where about 5% is converted to free tocopherol.  Tocopherol can be obtained from corn or other vegetable oil but also from petroleum, using toxic precursor chemicals, especially trimethylhydroquinone.   Hydroquinone is banned in the European Union because of its carcinogenic properties but although the FDA has expressed some concern about it, it’s still contained in products available over the counter in the US as a skin lightening agent, used to treat dark patches on the skin.

PUT WHAT IN YOUR PIPE AND SMOKE IT?

However, vitamin E acetate has not been found in all the e-liquid samples and its effects on the body when inhaled are not known for certain.  It is not used in any nicotine-based e-liquid by recognised manufacturers.   It may not be the guilty party in this case, however: according to the US Food and Drugs Administration, tests revealed a “broad range of chemicals,” including metals, cutting agents, pesticides and other toxins. In addition to e-liquid additives, the on-line magazine WebMD reported last year that “Scientists say the tiny metal coils that heat the liquid nitrogen in e-cigarettes may contaminate the resulting vapor with lead, chromium, manganese and nickel.”  Vitamin E acetate was found in 47% of the THC liquids tested.   Some 13% of those suffering ill effects deny having used the THC liquids, only available on the black market, claiming to have vaped only commonly-available and legally obtained nicotine-based e-products.   One is tempted to say “well they would, wouldn’t they?”

A number of leading medical organisations have now joined in the call to President Trump to get tough in tightening the regulation of vaping products.   The American Medical Association, the American Academy of Paediatrics and the American College of Physicians have expressed concern about the short- and long-term health consequences of vaping, especially for children. They have called for a total ban on flavoured vaping products, including the popular mint and menthol flavours, and for the permitted age for purchasing vaping equipment and liquids to be raised to 21.   They also want much stricter rules to apply over the marketing of all tobacco and vaping products to children.  The magazine Modern Healthcare quotes Dr. Jacqueline Fincher, president-elect of the American College of Physicians, who said “a lower amount of poison is still poison.”  

New York Paediatrician Dr. Alok Patel claims to have spoken about the use of e-cigarettes with his teenage patients, who told him that vaping is “trendy” and that the youngsters vape between lessons and during breaks, especially favouring the flavoured e-cigarettes.  I suspect a bit of teenage bravado could have led to a degree of exaggeration, here.  I can sympathise, though: a little rebellion is essential for teenagers.   At my school in England’s industrial North-East, I and most of my friends smoked and the local corner shop was happy to sell cigarettes in ones and twos to those of us in our school uniforms who couldn’t afford a whole packet.  As long as there were no adults in the shop to witness the transaction, of course.  The shopkeeper knew we were also below the permitted legal age of 16 for buying tobacco products.   

Patel says the teenagers are not vaping as an aid to giving up smoking: they enjoy the tastes, and that is why he wants a ban on flavourings, not on vaping products per se.   He mentions some of the flavours his young patients found so enticing: mango, unicorn puke, sweet tarts and crème brûlée, for instance.   Why would anyone be attracted to inhaling unicorn puke?   You’d have to ask a teenager; I’m too old to remember.   The Vapor Technology Association, which represents the interests of manufacturers, wholesalers and retailers of vaping products, claims that “if a federal flavour ban is enacted, more than 10 million adults will be forced to choose between smoking again […] or finding what they want on the black market.”  Or presumably switching to nicotine patches and special chewing gum to help them to kick the habit, as many others have done.  

PULLING THE LEVERS OF POWER

The VTA has embarked on a big campaign to get vapers to write to Trump and to Congress demanding the right to continue using flavoured products under the slogan “I vape, I vote”, suggesting the ban might persuade the vaper to switch their party allegiances.   The campaign goes on to say: “Tell President Trump how important flavoured vapor products are to you! Sec. Azar (Alex Azar, United States Secretary of Health and Human Services) just said on Fox that he & the President are removing flavors from the market! Make your voice heard.”  Corporate America has a loud voice and gets very angry if a health move threatens profits.   One hopes that when they make their own voices heard the vapers aren’t coughing too much.

Former Acting FDA Commissioner Ned Sharpless, M.D. takes a tour of the FDA’s Forensic Chemistry Center. The Center serves as the FDA’s premier national laboratory and is playing a critical role in fact-gathering and analysis for the ongoing incidents of lung illnesses following vaping product use. © Fda

I gave up smoking by temporarily taking snuff, like an 18th century stagecoach driver.   I don’t recommend it – it can be seriously damaging to health – but it was only until the cravings went away a few months later.   I still have the snuff box my former radio staff gave me but it’s empty these days.   I have no desire to try the stuff again.   Those who make and sell vaping products get very aerated (if that’s an appropriate word in this case) at the prospect of a flavour ban, which they say could lead to massive job losses and shop closures.   They have taken their concerns to law, too; a judge in Michigan recently halted a proposed ban on flavoured vaping products.   Legislators won’t find it easy to take on the well-heeled tobacco and tobacco products lobby, which would prefer no legislation because it would dent sales as well, perhaps, as an intrusion into the much-lauded freedom of choice in the US.  Unless you are under the age of 21 and want a beer, of course.

The sudden upsurge in vaping-related illness is a very recent thing.   Nicotine vaping products have been available all over the world for more than twelve years without anyone suggesting a health risk.   Although some of the people who became ill denied vaping products containing THC, most of them were young and could have feared parental or police involvement if they admitted it.   After all, cannabis is still illegal at a federal level and in most states. One young patient at New York University Langone Hospital denied vaping at all until his parents found a cartridge containing cannabis oil in his bedroom.   The US Centers for Disease Control still believe vaping is safer, especially if it helps the user to break their cigarette addiction.

WHAT’S YOUR POISON?

A study from the University of North Carolina found that the two primary ingredients found in e-cigarettes—propylene glycol and vegetable glycerin—are toxic to cells and that the more ingredients in an e-liquid, the greater the toxicity.   That’s irrespective of what else may be in the vaping liquid.   Even so, the overwhelming view of medical professionals is that vaping is safer by far than smoking cigarettes.   Britain’s National Institute for Health and Care Excellence, NICE, issues guidelines to medical professionals that acknowledge vaping as a means of breaking the addiction to tobacco.   “Many people use e-cigarettes to help them stop smoking. The committee considered it likely that they are substantially less harmful than smoking,” said Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE.   “As a relatively new product, the long-term impact of their short-term use as well as the long-term health impact of their long-term use is still developing. The committee was concerned that people who smoke should not be discouraged from switching to e-cigarettes because the evidence is still developing. Our guidance therefore recommends that healthcare professionals help people make informed decisions on their use.”   I think that means that vaping is safer than smoking, as well as proving that medical experts like to hedge their bets.

“The e-cigarette market in Europe has experienced a continuous expansion since 2008,” says the European Commission in a report on electronic cigarettes, “and, in 2014, was estimated to be worth approximately €2.16-billion. The UK, Italy, Poland and France are the largest EU markets. The biggest increase (+100%) in market value was noted in the UK, from 2013-2014.”   Despite this, the use by young people of vaping devices remains low in the UK, according to research by Public Health England, “with 1.7% of 11 to 18-year-olds in Great Britain reporting at least weekly use in 2018 (it was 0.4% among 11-year olds and 2.6% among 18-year olds).”   According to the figures published by the UK’s NHS Digital, more than 3.2-million adults in Britain use e-cigarettes; that’s 6.3% of the adult population.   Of them, 52% are former smokers, which suggests vaping is helping people to quit smoking.  The European Commission’s website does note one matter of concern: “An overview of the most popular industry websites indicated that hundreds of brands and sub brands are available on the EU market, with e-liquid available at different nicotine concentrations. It is also noteworthy that a few websites allowed for the purchase of base liquids in very high volumes (up to 25 litres) and/or refill mixing bowls, nicotine concentrates and syringes/pipettes for home mixing.”  

High Tech Electronic cigarette © Wikicommons

It is vaping equipment that has been modified in this way that is blamed by many for the upsurge in deaths and illnesses in the United States related to the use of e-cigarettes.   It also accounts for one problem noted by the National Academies of Sciences, Engineering and Medicine in the US: the fact that e-cigarette devices can explode and cause burns and projectile injuries.   The NASEM stressed that risk increased significantly when the batteries are of poor quality, stored improperly or modified by users.   However, the European Commission stated that of eight products requested for testing purposes three showed evidence upon delivery of having leaked in transit.   E-liquids can be harmful to skin and certainly to eyes and very toxic if consumed orally, which is why the Commission insists on fool-proof refill mechanisms and leak-proof packaging.  The Commission, while recognising the help e-cigarettes give to these trying to quit smoking, admits that some dangers may remain.   “There is growing evidence of potential risks from adverse effects in published cellular, animal and human studies,” says a report.  “These include: evidence of cytotoxic effects of some refill liquids, especially when nicotine and flavour substances are present; oxidative stress, inflammation of the respiratory system and effects on blood glucose in animal or tissue models; and reports of adverse effects in e-cigarette users, such as pneumonia, chest pain, hypotension, dizziness, and nausea.”

At a meeting with manufacturers’ representatives, TVECA and ECITA, the European Commission heard that a large majority of electronic cigarettes have a nicotine concentration below 30 mg/ml (the most common strength in the UK is 18 mg/ml). The manufacturers argued that concentrations below 30 mg/ml would not be sufficient to meet the nicotine cravings of heavy smokers, although no-one was aware of any research to back up that claim.    Although the European Union banned flavourings in cigarettes, it permits flavourings in e-cigarettes in the hope of luring smokers to at least try to give up.   And as for the other chemicals found in legal nicotine-based vaping products, the over-riding message is “don’t worry”.   They are present in minute quantities and are therefore far, far less likely to harm you than an ordinary cigarette.   The Irish Cancer Society warn that normal cigarettes contain some seven thousand chemicals, many of them poisonous and more than sixty of which are known to be carcinogenic.  They provide a handy list, with a note of other substances in which they’re found, which I shall put in parenthesis after each name:

Toluene                      (industrial solvent)

Carbon monoxide      (exhaust fumes)

Cadmium                    (batteries)

Arsenic                       (rat poison)

Ammonia                    (toilet cleaner)

Radon                         (naturally-occurring radioactive gas)

Hexamine                   (barbecue lighter liquid)

Methane                     (sewer gas)

Tar                              (road surfaces)

Acetone                      (nail varnish remover)

Polonium-210             (highly-radioactive isotope of polonium, discovered by Marie Curie.   Used in the murder of former Russian FSB agent and defector Alexander Litvinenko in November, 2006.  Also used in nuclear weapons)

Methanol                    (rocket fuel)

Methylamine              (tanning lotion)

Hydrogen cyanide      (poison)

Butane                        (lighter fuel)

It’s not a jolly list of suitable ingredients for a cake or anything else you might consider consuming.   Why would you want to draw these chemicals into your lungs?   Well, the good news is that apparently properly produced e-cigarettes contain far fewer really nasty things and will do you less harm, and it would be even better if they helped you to escape your addiction to smoking.   The health problems that have occurred in the United States seem to have stemmed from unregulated products, weak legislation and humankind’s endless willingness to tamper with things, especially while chasing a high.   Dr. Patel warns that “switching is not quitting” and “don’t be fooled by e-cigarette companies”.   The advice from the Federal Drug Agency seems the most sensible: “If you are an adult who used e-cigarettes containing nicotine to quit cigarette smoking, do not return to smoking cigarettes.”   As for youngsters experimenting with things they know their parents or teachers won’t like, warnings and flavour bans won’t stop them.   As the 8th century BCE Greek poet Hesiod wrote: “I see no hope for the future of our people if they are dependent on frivolous youth of today, for certainly all youth are reckless beyond words.”   But at least e-cigarettes are not heroin, cocaine, spice, LSD, psilocybin or amphetamines.   It’s better to be mildly rebellious than recklessly stupid.

Robin Crow

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