Young girl vaping on e-cigarette © Sarah Johnson

Since I last wrote an article for Europe Diplomatic Magazine about the downsides of vaping – the use of e-cigarettes and suchlike – a couple of years ago, more has been learned, none of it terribly good. Whether it’s worse for you than puffing away on an ordinary cigarette remains unlikely, admittedly, and I say that as an ex-smoker who gave up the habit more than three decades ago. I’m very glad I did, too; at least I cannot blame my current health problems on cigarettes; they’re all the fault of that unavoidable ailment that I call ‘anno dominitis’ – the passage of time, or simply old age. I’m absolutely certain that if I still smoked, my symptoms would be far worse. The latest research suggests that some of the chemicals in many commercially available vaping fluids can even lead to erectile dysfunction (ED) in quite young men. I think most males, given a choice between having something to smoke and being able to participate in the reproductive act or make love to the female of their choice would choose the latter. And there is, of course, a good side to vaping, the one the manufacturers harp on about: it helps smokers to quit. Ordinary tobacco has even worse side effects (such as killing you) and every smoker should strive to give up what is, after all, an unhealthy, unpleasant, and anti-social habit. Vaping wasn’t an option when I gave up cigarettes and quitting wasn’t easy. I’ve never regretted doing it, however.

There are an estimated nine-million users of e-cigarettes or vaporizers around the world. In most cases, the e-cigarettes or whatever are used as substitutes for cigarettes or cigars, perhaps even for pipes, although you don’t often see people smoking tobacco in pipes these days (whatever happened to Popeye the Sailor Man or Georges Simenon’s clever French detective, Maigret?) Perhaps they, too, suffered the side effects of smoking (or vaping) that left them unable to reproduce. Or simply dead. I smoked a pipe for a time when I first gave up cigarettes, but it does make the atmosphere muggy and wins you few friends in a public bar, however restful I found it at the time (but also messy and inclined to burn holes in one’s pockets). The advent of e-cigarettes in 2004 gave tobacco addicts a new alternative to smoking cigarettes or whatever else they used. Small substitutes such as e-cigarettes look like the real thing but vaping devices that are battery-powered use a heated coil to turn the liquid to vapour that the smoker can inhale. In most cases, the vapour contains such things as propylene glycol, vegetable glycerine, flavourings (a wide variety are on offer) and even – and often – nicotine. It seems a bit pointless to wean oneself off nicotine by inhaling nicotine, however. Such devices may not be completely safe, but they would seem to be a step in the right direction. Public Health England has stated that e-cigarettes and vaping are much safer than ordinary smoking. We should recall that the World Health Organisation reports that very nearly 7 million people die from the effects of smoking ordinary cigarettes every year. But we must also consider the bad effects vaping can have on a man’s sexual performance. Yes, it’s worth pointing out that the consumption of nicotine – by whatever means – has also been linked to erectile dysfunction (ED). CNN reported that otherwise healthy men who vaped nicotine daily were more than twice as likely to report experiencing ED as these who didn’t.

On the US National Institute for Health (NIH) website, vape users are reminded that whatever they choose to vaporize and inhale is still an “alien substance” that our lungs did not evolve to cope with. We all know that smoking tobacco is bad for us, so we ought to realise that putting smoke or vapour of some kind – or indeed any other extraneous substance – into our bodies is also unlikely to be to our long term benefit. According to the SomaTherapy-ED website, an American information source, tobacco, in whatever form, contains more than 40,000 chemicals, some of them known to be carcinogens. That’s in addition to the established links between smoking and such medical conditions as heart attack, stroke, lung disease, various cancers and – it seems – men’s sexual health.

Nicotine, for instance, damages blood vessels, and therefore affects the flow of blood to a man’s penis, the maintenance of which is essential to developing and maintaining an erection. The Massachusetts Male Aging Study concluded that smoking ordinary cigarettes almost doubles the likelihood of developing moderate-to-severe ED. Incidentally, the study focussed predominantly on younger men, showing that smoking is one of the major causes of ED in men under the age of 40. Nicotine can have a cumulative effect, too. According to SomaTherapy-ED, in relatively young men, aged between 18 and 44, the smoking of 20 cigarettes per day can cause a 2-fold increase in the risk of developing severe ED when compared with men who smoke less. Furthermore, unlike other symptoms that a man may develop, ED may not be reversible when (if) they subsequently give up smoking, although the status of a man’s erection has been found to improve in 25% of formerly heavy smokers within one year of quitting. The website also points out that since ED is caused in proportion to the amount of nicotine consumed, replacement therapies that still involve doses of nicotine – even these that deliver through a patch – may not help to overcome ED. Indeed, research shows that nicotine damage can have a serious effect on sexual arousal, with one study centred on men with the average age of just 21, and who had not been heavy nicotine users. It was found that the use of a single high-dose nicotine patch substantially reduced erectile response to any kind of stimulation.

LIGHTING THE WAY OR SNUFFING IT OUT?

Perhaps most significantly, the British Medical Journal (BMJ) published an on-line article about the effects of vaping in terms of helping a smoker to quit. The original article said ‘yes’, it did, but this was later subject to an updating that changed the verdict to ‘no’, it did not, with Jørgen Vestbo, Andrew Bush, and Jonathan Grigg arguing that there is already enough nicotine addiction. “For decades, smoking rates in the UK have been declining, and few teenagers see themselves becoming smokers,” the report said. “This has been achieved without e-cigarettes, and the decline in smoking has not accelerated after the introduction of e-cigarettes.” There has been a move to have e-cigarettes licenced as a medicine, partly (it’s claimed) so that availability could be controlled by the medical profession, but a number of experts have opposed this idea, largely because it gives a kind of respectability to the manufacture and sale of these products. The BMJ conducted a survey of the available literature on the subject.

According to the this research, it: “revealed a total of 40 articles out of which 29 were included in the review. Electronic cigarettes (ECIGs) achieved modest cessation rates with benefits of behavioural and sensory gratification. On the contrary, in many studies where ECIGs were introduced as an intervention, participants continued to use them to maintain their habit instead of quitting.” The scientific research found a total of 22 toxic substances apart from nicotine in the liquid of ECIG cartridges and their emissions. “Many compounds had lower concentrations in ECIG compared to tobacco smoke. There existed a wide variation in the content of ECIG cartridges and strengths of nicotine in refill solutions. It has been observed that the second generation ECIGs delivered nicotine with a similar kinetic profile to conventional cigarettes.” In 2013, the American Food and Drug Administration (FDA) gave market authorization to ECIGs “for quitting smoking and cigarette substitutes. The United Kingdom also advocates ECIGs as a medicinal aid to quitting but bans it from workplaces and other public spaces”. India along with many other countries has yet to come up with a formal regulatory stand regarding ECIGs.

In early 2021, the World Vapers’ Alliance organised what they called a “Covid-friendly demonstration” (friendly to the attendees, not to SARS-CoV-2 viruses) of their products at the European Parliament in a bid to persuade MEPs that E-cigarettes and other vaping devices can help defeat or reduce the consumption of ordinary tobacco. Speaking about the demonstration, Michael Landl, Director of the World Vapers’ Alliance said: “While we can’t be there in person, we wanted to make sure that MEPs hear us and see us. 700,000 people die every year in the EU due to smoking induced cancer but as vapers, we have seen first-hand how vaping helps to quit smoking. Europe’s Beating Cancer Plan must endorse vaping as an effective method to help smokers move to a safer alternative and reduce cancer in Europe.”

As a neutral observer (who managed to give up smoking without the aid of such devices) I feel I must point out that, understandably, he wants to sell his members’ products. After all, he must want to see more people obtaining and using ing vaping devices. At the special meeting, Italian MEP Pietro Fiocchi of the centre-right European People’s Party (EPP), high-lighted studies showing the much lower cancer risk of vaping compared to smoking, while MEP Tomislav Sokol from Croatia, also EPP, asked about how the concept of ‘harm reduction’ could help in fighting cancer.

Additionally, another EPP member, German MEP Peter Liese, highlighted the need to ensure vaping is not as restricted as smoking saying: “Stop smoking is easy to say, but for those who are addicted it is very difficult.

That is why I think we need to be a bit more open towards e-cigarettes. So at least we need to make sure that e-cigarettes are not more difficult to access than tobacco.” Difficult, yes, but as I have proved, far from impossible. Welcoming these comments (none from other political groups were quoted), Michael Landl said: “I’m encouraged by the increasing open-mindedness of MEPs to how vaping can help reduce smoking and help reduce cancer.” Of course he is.

America’s National Library of Medicine (NIH) is less impressed, reminding the readers on its website that its own research, using standard e-cigarettes with a variety of flavourings, is more ambivalent in its results. “This laboratory study examined the relationship between liquid nicotine concentration and plasma nicotine concentration and puffing behaviour in experienced ECIG users. Sixteen ECIG-experienced participants used a 3.3-Volt ECIG battery attached to a 1.5-Ohm dual-coil ‘cartomiser’ (which consists of a metal or plastic casing housing a single of dual coil atomizer wrapped in a roll of polyfill material to absorb the e-liquid) loaded with 1 mL of a flavoured propylene glycol/vegetable glycerine liquid to complete four sessions, at least 2 days apart, that differed by nicotine concentration (0, 8, 18 or 36 mg/mL).”

The report then goes into considerable scientific detail not suitable for an article like this. However. in another report the NIH mentions how in the United States there has been an “outbreak of lung injuries and deaths linked to vaping.” The report goes on to mention a range of other health issues: “Vaping exposes the lungs to a variety of chemicals,” it states. “These may include the main active chemicals in tobacco (nicotine) or marijuana (THC), flavourings, and other ingredients that are added to vaping liquids. Plus, other chemicals can be produced during the vaporizing process.” The real problem here is the frequent inclusion of nicotine in commercially available vaping liquids, which must surely be a hindrance to anyone using vaping as a means of giving up smoking. The study seems to suggest that inhaling nicotine through a vaping device is slightly less harmful than smoking a cigarette in cases where regular smokers make the switch to vaping completely, but it’s still hazardous to your health. According to Dr. Thomas Eissenberg, an expert on tobacco research at Virginia Commonwealth University who is quoted on the NIH website: “Your lungs aren’t meant to deal with the constant challenge of non-air that people are putting into them – sometimes as many as 200 puffs a day – day after day, week after week, year after year.”

Nicotine is, of course, a natural pesticide, produced by the tobacco plant, the nicotiana in its various varieties, to make its leaves taste unpleasant to invading insects and, if they persist, to kill the attackers. It was used by native Americans to protect their crops from pests. The trouble is that it also kills bees, birds, fish, and any mammals snacking on the plant. Its main effect, however, is to repel carrot flies and flea beetles, and also whiteflies, gnats, aphids, thrips and leaf miners. It’s a nerve toxin, and if it can kill off these persistent pests, just imagine what it can do to your lungs. However, there is evidence that vaping is safer than smoking tobacco. Public Health England (PHE), a government body, is convinced.

On its website it says: “The estimate that e-cigarette use is around 95% safer than smoking is based on the facts that the constituents of cigarette smoke that harm health – including carcinogens – are either absent in e-cigarette vapour or, if present, they are mostly at levels much below 5% of smoking doses, mostly below 1% and far below safety limits or occupational exposure.” PHE also states that: “the main chemicals present only in e-cigarettes have not been associated with any serious risk.”

HE WHO DIES THIS YEAR IS QUIT FOR THE NEXT (Shakespeare, Henry V)

That’s very different from the findings of some American researchers, and even PHE adds a cautionary note: “But e-cigarettes are not risk free, and more research is needed on how long-term vaping can affect the lungs and overall health. For example, we know that vaping can have some impact on inflammation in the airways which might cause harm over long periods.  We don’t recommend anyone using e-cigarettes unless they are trying to stop smoking.” In other words, they may be safer than cigarettes but they’re still not really safe, although they may help you to give up the far more dangerous cigarettes. They can still cause or worsen chronic obstructive pulmonary disease, although some of those who switched from ordinary cigarettes have reported an improvement in that condition, in cases where they were already sufferers. Furthermore, according to PHE, “e-cigarettes could be contributing to at least 20,000 successful new quits per year and possibly more.”

In the United States, the National Academies of Science are similarly enthusiastic, up to a point. “Evidence suggests that while e-cigarettes are not without health risks, they are likely to be far less harmful than conventional cigarettes,” the report said when published in 2018. “They contain fewer numbers and lower levels of toxic substances than conventional cigarettes and using e-cigarettes may help adults who smoke conventional cigarettes quit smoking. However, their long-term health effects are not yet clear.” It also points out that: “There is substantial evidence that nicotine intake from e-cigarettes among experienced adult e-cigarette users can be comparable to that from conventional cigarettes.” In which caser, making the switch is a case of “out of the frying pan, into the fire”. The medical profession, it seems (or most of it, at least) can see mainly benefits, rather than danger, from vaping, but only if it used as a way of helping to stop the user from being addicted to conventional cigarettes. “Our new review,” states the PHE, “reinforces the finding that vaping is a fraction of the risk of smoking, at least 95% less harmful, and of negligible risk to bystanders. Yet over half of smokers either falsely believe that vaping is as harmful as smoking or just don’t know.” The report makes an interesting comment on the toxicity of nicotine that any carrot flies, flea beetles, whiteflies, gnats, aphids, thrips, or leaf miners might find surprising, if reading this while coughing in the flower beds: “People smoke for the nicotine, but contrary to what the vast majority believe, nicotine causes little if any of the harm.” That sentence may come as a surprise. “The toxic smoke is the culprit and is the overwhelming cause of all tobacco-related disease and death.”

It all sounds very positive for the makers and purveyors of vaping equipment and liquids, but the World Health Organisation (WHO) sounds a note of caution: “E-cigarette emissions typically contain nicotine and other toxic substances that are harmful to both users, and non-users who are exposed to the aerosols second-hand,” says the website. “Some products claiming to be nicotine-free have been found to contain nicotine. Evidence reveals that these products are harmful to health and are not safe. However, it is too early to provide a clear answer on the long-term impact of using them or being exposed to them.” The use of electronic nicotine delivery systems (ENDS) is known to increase the risk of heart disease and lung disorders, as well as posing “significant risks to pregnant women who use them, as they can damage the growing foetus.”

Recently there has been growing evidence that the use of vaping devices could be associated with lung damage, known as “e-cigarette or vaping associated lung injury”, or EVALI, with enough cases to get the US Centers for Disease Control and Prevention (CDC) involved. This gas led the United States Centers for Disease Control and Prevention (CDC) to activate an emergency investigation into EVALI on 17 September 2019. By then, a total of 2,668 cases of EVALI had been reported from all 50 states, plus the District of Columbia, Puerto Rico and the US Virgin Islands, with 60 deaths confirmed. “Among 2,022 hospitalized cases with information on substances used,” says the WHO report, “1,650 (82%) reported using any THC-containing product, and 1,162 (57%) reported using any nicotine-containing product; 669 (33%) reported exclusive THC-containing product use, and 274 (14%) reported exclusive nicotine-containing product use.”  In that case, perhaps not typical of most vapers, but still a worrying development.

SEX AND SMOKING

We started, however, by talking about the possible effects of vaping on male sexual performance and fertility. It remains an issue, according to the ExSeed website: “Essentially it affects all functions related to reproduction including semen volume, sperm motility (movement), sperm morphology (shape), sperm genetic material, and causes erectile dysfunction.” ExSeed admits that research into the relationship between male sexual ability and vaping has been scant, but it believes what little scientific evidence there is looks to be negative: “There is not much research on vaping and its effects on fertility,” it admits on its website, “but the limited research out there suggests that it affects fertility in a negative way. One small study, which took place at the University College of London, indicated that the e-liquid in itself could damage sperm cells.” One problem would seem to be that such evidence as exists is based on tests carried out on rodents. “The only study on e-liquids, which was published in 2016, showed that male rats exposed to e-liquids with and without nicotine for four weeks, showed a significant decrease in sperm count of both groups, with the biggest decrease in the nicotine exposed rats, suggesting that e-liquid may harm fertility even without nicotine.”

But rats are not habitual smokers as a rule, so it’s not clear how much notice we should take of it. I do feel sorry for the rats, however.

As I mentioned earlier, it’s not just the intake of nicotine through a cigarette or even an e-cigarette that causes concern. According to ExSeed, it’s also chewing tobacco, snuff, and nicotine replacement therapy that might harm male fertility. Another website, Conceive, shares ExSeed’s concerns. “We know that smoking (cigarettes) affects male fertility, largely due to 4,000+ chemicals in the cigarette themselves. But what about just nicotine alone? What about the other products in vape liquid?” the website asks. “Turns out, nicotine itself is a problem. It significantly lowers sperm count, sperm motility, sperm viability, and increases the percent of sperm with abnormal morphology. It also reduces the weight of the testes, testosterone level, and testicular antioxidant status.”

The problem for anyone trying to assess the dangers by reading the many and varied reports by various experts and examining their scientific research is that you can find virtually any opinion you like, seemingly backed up by well-researched facts. Disentangling them is the challenge, along with drawing definitive conclusions. The American medical website, Smart Surgery, Warns on its website: “There is no such thing as “safe smoking, as more research is still required before we know the full revelation on vaping’s health effect on the human.”

Health researchers in New York have come up with an unexpected conclusion : since some 90% of the nicotine inhaled from cigarettes is excreted in the urine, there’s a strong possibility that nicotine from e-cigarettes could lead to a risk of bladder cancer. Further research, following on from this, led them to conclude that e-cigarette smoke could damage the DNA in human bladders in much the same way as can second-hand smoke from ordinary cigarettes. Even here, though, the report concludes, despite its apparent opposition to vaping, that e-cigarettes are safer than the conventional kind. “E-cigarettes also contain nicotine but not as much as regular cigarettes,” says the website. “The nicotine content in a single cigarette varies but may contain about 6 milligrams (mg) on the low end to as much as 28 mg. The average cigarette contains about 10 to 12 mg of nicotine.  In comparison, e-cigarettes contain, on average, 0.5 to 15.4 mg.” The same website also expresses a negative viewpoint regarding a man’s sexuality. “More than 20 million American men suffer from erectile dysfunction (ED). This inability to either achieve or maintain an erection firm enough for sexual intercourse is directly impacted by men who smoke or are exposed to second-hand smoke. ED is the result of poor blood flow to the penis.  Men who smoke are harming the blood vessels that supply this blood flow, resulting in a man’s inability to get or keep an erection.”

The ‘Inverse’ website by Katie MacBride from October 2021 is equally worried about the effects of vaping on male sexual health, when it’s already known that ordinary smoking adversely affects it: “Because nicotine and other additives are also in e-cigarettes,” Omar El-Shahawy, Assistant Professor at New York University’s Grossman School of Medicine and lead researcher on the study, told Ms. MacBride. His colleagues wanted to know if the relationship between e-cigarette use and ED would be similarly strong. After all, in a recent study published in the American Journal of Preventative Medicine, researchers revealed that men who vape with nicotine on a daily basis are more than twice as likely to experience erectile dysfunction as those who never used e-cigarettes. So, one must conclude that vaping may – and I stress the word ‘may’ – be less harmful to a man’s sexual capability than smoking a normal cigarette, but it’s a value judgement that leaves a residue of risk: “Long-term studies have shown that the intensity of cigarette smoking is correlated with a greater degree of erectile dysfunction. That’s because nicotine is a vasoconstrictor, causing blood vessels to narrow, reducing blood flow. Erections rely on good unrestricted blood flow to the penis, thus this constriction makes that less likely to happen.” So, take the risk if you want to (or if your addiction to nicotine leaves you little or no choice) but don’t do so without considering what the side effects may be.

DEATH OR DYSFUNCTION

Research reported on the Inverse site would be bad news for regular vapers. The researchers looked at the experiences of a range of men with a varying degree of problems. Of the 45,971 survey respondents, the researchers focused on two groups: a full sample of 13,711 males aged 20 and older who had answered a survey question about erectile dysfunction, and a subset , made up of a restricted sample of 11,207 males aged 20 to 65 years with no prior cardiovascular disease diagnosis.

“Compared to those who never vaped,” it said, “daily users were more than twice as likely to report having erectile dysfunction — this was particularly true for the men in the restricted sample: 2.2 times as likely for the full sample, and 2.4 times as likely for the subset. In the subset, 10.2 percent of respondents reported having erectile dysfunction to some degree. Of these men, 5.5 percent were occasional vapers; 2.5 percent were daily users.” El-Shahawy says this was not unexpected. “Nicotine is nicotine in any form — the theory is that e-cigarettes can deliver high nicotine levels perhaps — at least some of them do,” he explained. It depends on the vaper’s individual choice of vaping liquid.

El-Shahawy admits that he does not yet know if the effects of vaping in sexual performance are as severe as those from ordinary smoking. That requires further research. “This is the first study [looking at the connection between e-cigarettes and erectile dysfunction and we can’t quantify the risk based on one study,” he told the website. “Also, more comprehensive analysis with other measures for [erectile dysfunction] assessment is needed,” he added. El-Shahawy wants to study whether e-cigarette use also affects female sexual health and he hopes to look at longer-term patterns linking erectile dysfunction and e-cigarette use.

“Ultimately, it makes sense that vaping nicotine would have some of the same effects as smoking nicotine on the body,” he said.

One thing is certain: smoking of any kind, whether using old-fashioned cigarettes, vaping devices of some sort or any other nicotine delivery system is definitely bad for you. The question is: how bad? It would seem that vaping is the healthier option, if only slightly and only if it leads to the vaper giving up normal smoking, and it’s nowhere near as safe as abstinence. If it came to a choice, which would most men prefer? The ability to have sex with a partner or a quick puff on a smoking device? I don’t think we need concern ourselves with the answer. When I was in my teens, I recall being told a joke that went like this: “Question: what are the three best things in life? Answer: a drink before and a smoke afterwards.” It would seem that doing it the other way round may not be advisable. In the longer term, it may not even be possible.