by ecancer reporter Will Davies

Across many countries, smoking rates have plummeted in the last two decades.

This has come due to social and legal efforts, including indoor and public smoking bans, public health awareness campaigns, and higher prices, all of which is improving life expectancy for smokers, former smokers and their families.

Among the most recent developments is the widespread availability of e-cigarettes, an aerosol or ‘vapour’ based means of nicotine administration that simulates the smoking experience with heated nicotine fluid containing a choice of flavourings heated over a coil to substitute tobacco smoke.

There is little debate left as to where e-cigarettes can help smokers quit, with a growing body of studies linking daily use to increased chances of success, that e-cigarettes are less addictive than cigarettes, and the efficacy of nicotine reduction in e-cigarette fluids as a way to reduce dependence, as with nicotine gums and patches.

A significant portion of smokers attempting to quit report having used e-cigarettes, boosting 3 month quitting rates and overall annual quitting in the US.

The latest research has even put a number to the potential gain in life expectancy, assuming the adoption of e-cigarettes by all tobacco users, at up to 86 million years, preventing 6.6 million premature deaths.

A relative newcomer to the tobacco-control scene, e-cigarettes have taken off to tremendous market success, and are even credited with slowing sales for nicotine gum and patches.

In the UK, e-cigarette usage has doubled over the last 2 years, with over 800 vaping shops opening nationwide in 2016, not including mixed-purpose retailers.

This final point raises a curious dilemma – if more people are quitting, does the booming business in e-cigarette device show a direct transfer from one delivery mechanism to another, or is there more to liquid nicotine business than just cancer control?

If the report that less than 1% of internet searches for e-cigarettes focussed on smoking cessation are to be believed, that may be the case.

Vaping has emerged as a hot trend in the last three years, with ‘vape trick’ videos scoring millions of views online, and dozens of magazines, podcasts and online groups forming to report on ‘vape culture’, brand updates and legal standing of e-cigarette usage globally.

Visibility and acceptance of vaping as a hobby or way of life are recurrent topics, with articles discussing normalizing ‘our industry’ giving a brief glimpse into the personal investment may users project onto their use. 

The marketing of e-cigarettes in the above material trends towards the young, counter-culture niche, and a broader analysis of television, print and online advertisements in the Journal of Adolescent Health showed a correlation between e-cigarette marketing and teen usage.

The ability to easily purchase e-cigarettes online oversight means access is no issue for children, and many parents remain unsure of whether using e-cigarette devices are safe or not, or not aware of the damage fluid spills and ingestion could cause.

Other research has linked e-cigarette marketing material to tobacco craving and relapse by otherwise intermittent smokers, and even tempt long-time quitters.

Separate studies have also linked the sweeter flavourings of e-cigarette fluids to increased youth appeal, and identified the ‘fun factor’ as a driver of teen use.

While most of the teens in that study who reported using e-cigarettes had personal or family histories of tobacco usage, three further studies have linked e-cigarette usage by schoolchildren and teenagers as increasing the likelihood of them using conventional tobacco products at least once.

The latest statistics available from the FDA report a ten-fold increase in e-cigarette usage among high school students, over 2 million child or teen users across the US, though this comes alongside falling rates tobacco cigarettes by children and their families, showing a likely cross over.

Further research has refuted these findings, with only small numbers of teens surveyed in Wales regularly using an e-cigarette without previously smoking cigarettes, suggesting that any childhood dalliance is unlikely to be habit forming, though longitudinal studies are few and far between at this point.

These mixed results, early in the lifecycle of an emerging business, have led to statements from the FDA, US Surgeon General and Cancer Research UK advising prevention of childhood use, and the suitability of e-cigarette platforms for smoking cessation, based on common sense use.

So, the take away message here is that e-cigarettes are generally safe then?

Those sweet flavours which children reported as a major appealing factor to e-cigarette use include cinnamaldehydes which, based on samples obtained from users, directly suppress immune function in nasal and respiratory tissues.

When heated, cinnamaldehydes and similar flavourings metabolise directly into toxic aldehydes and other carcinogens, including benzene production at high temperatures.

Other models have linked nicotine containing and nicotine free e-cigarette fluid with DNA damage on par with tobacco cigarettes, due to other additives and flavours in the fluid.

This is feared to have an especially severe effect in younger users, with persistent coughs and bronchitis reported so far, and asthmatic users doubly susceptible.

Research in Environmental Research has identified toxic metals, including cadmium, chromium and lead, leeched from the heating coil of devices into fluid during aerosol generation, and, in even more unusual circumstances, thermal runaway in e-cigarette batteries has resulted in the device rupturing and exploding in users pockets.

In control of cardiovascular disease, initial indications that human heart cells respond less to e-cigarette aerosol than tobacco smoke have been matched by later findings that ecigarette users were more likely than non-smokers to experience increased adrenaline levels in the heart and increased oxidative stress.

On the other hand, other research reports that e-cigarette vapour

• doesn’t cause mutations in bacterial strains as tobacco smoke would
• causes no DNA damage or cell stress in in vitro tests
• that airway cells exposed to vapour in smoking robot had no response whatsoever
• was all together less toxic to lung cells in lab tests
• resulted in less double-stranded DNA breaks than tobacco smoke
• caused significantly fewer changes in inflammatory cytokine expression than tobacco smoke
• contained 95% lower toxicant levels than tobacco smoke
• contained formaldehyde levels below WHO guidelines
• generally reduced risks compared to tobacco cigarettes

All of the above comes from R&D at British American Tobacco, and if anyone knows about the risks of smoking, it's gonna be them...

What to make of this all?

As ever, common sense prevails – any time you introduce a new element to a system, something in the system will change, be it drinking anything besides clean water or breathing anything besides fresh air.

E-cigarettes are not 100% risk free, but so far those risks pale in comparison to the tremendous global health burden associated with tobacco.

Their use to ease smokers off tobacco cigarettes and towards smoking cessation is recommended, though regulation around the content of flavourings and safety of devices requires review.

Should children and teenagers use them for fun?

No.

Will they?

Certainly, just the same as every other thing children are told not to do.

Will waving Skittles-flavoured vapour toruses around a stage ever actually look cool?

Not in this reporters opinion, but who am I to judge?