Chapter 6

Recognizing the Risks of Vaping

IN THIS CHAPTER

Bullet Comparing vaping to smoking

Bullet Assessing the health risks of vaping

Bullet Looking at whether vaping leads to smoking

We would love it if all humans enjoyed breathing clean, fresh air, devoid of any pollutants. But it would also be nice if everyone had a great diet of healthy food, never consumed too much alcohol, got plenty of exercise, got just the right amount of sleep, drove safely, never gambled to excess, never used illicit drugs, and abstained from risky sex.

As far as we can tell, our preferences are unrealistic for the vast majority of people. Some people live in polluted cities, others lack adequate nutritious food, too many don’t get sufficient exercise or sleep. And about a billion people around the world use some form of tobacco.

Fewer people vape. But their numbers are climbing rapidly. In 2011, about seven million people reported vaping, and as of this writing, the number is approaching 50 million adults worldwide. This exponential growth explains the surge in interest about the health effects of vaping.

In this chapter, we explore the controversial debate about smoking versus vaping safety. Then we review what’s known so far about specific health risks of vaping. (See Chapter 2 for more details concerning the risks of consuming tobacco in its various forms.)

We conclude with a discussion of the potential of vaping to lead people to pick up a combustible smoking habit. That concern is especially troubling, given that e-cigarette use is associated with higher rates of regular smoking by adolescents. (See Chapter 7 for more information about the implications of vaping among tweens and teens.)

Answering the Million-Dollar Question: Is Vaping Safer than Smoking?

Yes, probably — but with numerous caveats. In a head-to-head contest, smoking appears more dangerous than vaping. Think of smoking like playing professional football without a helmet or protective gear. Chances are, you’re going to get hurt. Badly. You may even die. Half of all chronic smokers will eventually die from illness directly linked to smoking.

However, if you suit up in appropriate protective clothing and a helmet, you’ll have a much better chance of surviving that football game. Nonetheless, you’ll still be running substantial risks of getting hurt, especially over time. Consider all the serious brain injuries increasingly reported among former professional football players, even though they used helmets. For that matter, even in the short run, it’s a rare NFL game that you don’t see at least one player carried off on a stretcher. So, let’s say that vaping is more like playing football for years with protective gear: safer but far from safe.

Yet, many in the public don’t realize that vaping is probably safer than smoking. Surveys have found that increasingly, the public views e-cigarettes as equally, if not more, dangerous than regular, tobacco cigarettes. That may be because of frequent news articles about the dangers of vaping. Relatively few news articles appear that detail the dangers of cigarette smoking. That’s because those dangers have been well known for decades and the topic is neither newsworthy nor controversial.

Scientists know that cigarette smoking kills, and the risks are well established. A lot of the damage from regular smoking is caused by the combustion of tobacco, which produces toxins that damage the cell linings of the lungs. That damage makes the cells more vulnerable to the effects of cancer-causing chemicals (some caused by the combustion itself) found in regular cigarettes.

Vaping appears safer, but many of the risks associated with vaping are not yet fully known. Long-term studies are sorely lacking because vaping is a relatively new phenomenon. Nevertheless, scientists have reached a reasonable consensus that vaping is safer than regular cigarettes.

Tip Although vaping potentially exposes vapers to an array of toxic chemicals, there are fewer chemicals and the levels of those chemicals are much less toxic than those found in regular, combustible cigarettes.

You should know that conclusions about the safety of vaping are complicated because of the variety of devices and substances. In fact, there are literally hundreds of different types of vaping devices that produce variable levels of heat and amounts of vapor (see Chapter 5). There are almost an infinite variety of e-juice combinations. And the concentrations of these substances also fluctuate widely. For example, some e-liquid contains exceptionally high levels of nicotine. Other formulations contain no nicotine whatsoever. Still others deliver various flavors, tetrahydrocannabinol (THC), cannabidiol (CBD), and so on (see Chapter 5). Different risks likely depend on the actual device and specific ingredients in the e-liquid.

Warning Although most forms of vaping appear generally safer than smoking cigarettes, we want to be clear that we do not advocate starting vaping if you’re not a smoker. Chapter 12 provides information on using vaping as one means of either quitting smoking or reducing overall harm from smoking — however, this use is only recommended for the small percentage of people who smoke heavily, have tried quitting by a number of other means, and are either unable or unwilling to quit smoking entirely.

Warning Because vaping in the United States is still lightly regulated, using e-cigarettes may confer greater risks than if purchased in the United Kingdom, where there are strict controls over the industry. So, for now, the U.S. Centers for Disease Control and Prevention (CDC) recommends against using vaping to quit smoking.

Technical stuff The U.S. Food and Drug Administration (FDA) is often cited as having not found e-cigarettes to be a safe and effective method for smoking cessation efforts. One reason it hasn’t reached this conclusion is that it hasn’t yet studied e-cigarettes for this purpose. In the United Kingdom, the National Health Service (NHS) has assessed the issue and recommends e-cigarettes for the purpose of quitting smoking. More research is badly needed on vaping as a smoking cessation strategy because what we have now is both conflicting and controversial.

Examining the Dangers of Vaping

If you do decide to take up vaping, whether as an aid to quitting smoking or as a hobby or recreational activity, you should at least be aware of what’s currently known about the risks. Again, our advice is to refrain from another, potentially addictive habit — a habit that will cost you time, money, and possibly your health. After all, this book is about quitting, not starting!

Ultimately, the choice of whether to vape is yours. The sections that follow lay out the major, known risks of vaping. Time will no doubt reveal more.

Warning When people smoked cigarettes during the Roaring Twenties, they had little concern about the health consequences of their new habit. Serious warnings didn’t start appearing until around 1950. In part, that’s because many of the diseases associated with cigarette smoking take decades to develop. Vaping today is much like smoking cigarettes in the 1920s. Yes, there are far fewer “known” toxins in e-cigarettes, but we just don’t have long-term data to know for sure what the risks are over time.

Becoming addicted

Every morning we drink coffee. And we enjoy coffee. Any morning that our coffee routine is interrupted, we crave coffee. We both consider ourselves “mildly addicted” to caffeine. Not a big deal unless coffee is not available. And we have both had periods of time without caffeine. However, not all addictive drugs are as cheap and readily available and have as relatively high health/safety profile as caffeine. In addition, caffeine’s downside risks are minimal.

Nicotine has many similar effects on the body as caffeine. So, why is it such a serious issue to be addicted to nicotine? Part of the concern has to do with the way nicotine is consumed. With cigarettes and vaping, people become enslaved by the routine of having to take numerous puffs all day long.

Most people generally drink coffee one, two, or at most, three times per day. That’s partly because caffeine has a much longer half-life than nicotine, meaning that nicotine remains in the body a much shorter time than caffeine does. Thus, to maintain the good feeling, you must replenish nicotine much more frequently.

Then, of course, there’s also the hassle factor of nicotine addiction. You don’t see too many “no-coffee” zones out there, and no one else unwillingly consumes your coffee when you drink it. With smoking and vaping, severe limits are placed on where you can consume, and everyone around you inhales some of your nicotine, whether they want to or not.

One of the highest risks associated with vaping nicotine is that you’ll become addicted to the substance. Nicotine is one of the most addictive drugs out there (and more so than caffeine). A major characteristic of becoming addicted is that you continue to seek out your drug of choice despite negative consequences.

Negative consequences of a nicotine addiction may include significant risks to health. Do you really want your life and the lives around you controlled so much by a drug?

Chemical concerns

If you visit a local vape shop and ask what chemicals are in the e-liquid, they’re likely to tell you it comes down to just vegetable glycerin, propylene glycol, and whatever substance you’re wanting added such as nicotine, CBD, or THC. They may inform you that various flavors are in the liquid, too. They’ll likely assure you that the flavors are all safe and that many are FDA approved. (See Chapter 5 for more information about e-liquids or, as they’re also called, e-juices.)

What they won’t tell you is that these substances are mainly approved for human ingestion, not inhalation. For example, consider pepperoni pizza. It tastes great, and it’s relatively safe. But what would happen if you liquified the pizza, heated it, and inhaled the vapor? We don’t know the answer to that question, but just intuitively, it seems like it wouldn’t be a good thing to do to your lungs.

In other words, most chemicals used in vaping have never been subjected to scrutiny for safety when inhaled. Because literally thousands of chemicals are used for flavoring in e-liquids, that leaves you quite uncertain as to the safety and nature of e-liquids used for vaping.

Furthermore, the chemicals that are put into e-liquids can break down and change when heated and vaporized. Just a few of the chemicals and toxicants your body may encounter when vaping include

  • Acetaldehyde
  • Acrolein
  • Acrylamide
  • Benzene
  • Diacetyl
  • Formaldehyde
  • Furfural
  • Nitrosamine
  • Phthalates
  • Various volatile organic compounds

And, as we said, these aren’t the only chemicals you could be exposed to when vaping. Some of them are known carcinogens. Sometimes there are chemicals that are not listed on the labels of the e-liquids. Furthermore, toxic substances emitted from e-cigarettes vary with the device used and the contents of the specific e-liquid. At the same time, to be fair, you should know that your exposure to toxins from e-cigarettes is substantially lower than what you inhale from regular cigarettes.

Mining metals

Your local vape shop manager probably won’t mention this, but there are studies indicating that e-cigarette aerosol contains metals. Metals are highly toxic and can affect multiple organs. However, this issue is still waiting for answers from good studies to address specific long-term health effects (or lack thereof) from vaping.

The levels of metals vary with the type of device in question. Most studies to date have focused on cig-a-like products and vape pens (see Chapter 5).

It’s believed that heated coils and other components of the vaping device are the primary source of these metals, which are thought to leak into the aerosol. A few of the metals that have been found include

  • Aluminum
  • Chromium
  • Iron
  • Lead
  • Manganese
  • Nickel
  • Tin

The exact levels and concentrations vary among devices and, thus, long-term health effects are more difficult to definitively ascertain or predict. Cadmium is also found in e-cigarettes; however, at much lower levels than it’s found in combustible cigarettes. Cadmium has high toxicity and causes lung and kidney disease.

Getting to the heart of the matter

Like combustible cigarettes, e-cigarettes carry nicotine into the lungs and circulate through the cardiovascular system. The nicotine is carried by microscopic particles in the aerosol. These ultra-fine pollutants have been linked to high blood pressure, coronary artery disease, and heart attacks.

In a large survey of close to 100,000 participants, researchers found that e-cigarette users had significantly higher risks of heart attack and coronary artery disease than non-smokers or non-vapers. The risk suggested a 34 percent increased chance of having a heart attack for e-cigarette users.

This type of study demonstrates a possible association, but it can’t truly establish a causal relationship between vaping and heart disease. Furthermore, the authors acknowledged that regular smoking confers a much higher risk of cardiovascular disease than vaping. One preliminary study indicated an improvement in heart function when combustible cigarette smokers switched to vaping for a month. Once again, more data over long periods of time is needed.

Irritating lungs

E-cigarettes have been associated with increased risk of asthma, chronic bronchitis, and pulmonary inflammation. In addition, people who vape have decreased immunity and increased mucus secretion. There is concern that e-cigarette users may be predisposed to respiratory infections.

Warning Healthy adults and teenagers have been taken to emergency rooms with shortness of breath, chest pain, and fatigue. Some of them have ended up in intensive care with severe lung damage, and some have died. They all reported vaping prior to their illnesses. People have been vaping in large numbers for over a decade, and these cases have only recently emerged, so it seems likely that new contaminants have gotten into the supply chain.

Nonetheless, as of this writing, it appears that the only apparent common denominator for these lung damage cases is vaping. Those stricken reported using various devices with different e-liquids. A substantial majority (over 75 percent) admitted to vaping THC, some obtained legally and many others not. Vitamin E acetate is often used with THC to make a proper vaping consistency. Vitamin E, when inhaled, appears to cause a severe inflammatory reaction. Another possible culprit is contamination from using devices with bad e-liquid mixes and/or problematic flavorings of unknown toxicity. Careful reporting and study will be needed to track down the true source(s) of the problem. The bottom line is that the vaping industry is in dire need of robust study and regulation.

Warning While investigating a recent spike in pulmonary illnesses related to vaping, the CDC recently recommended the following:

  • Never buy e-cigarettes or e-liquids off the street.
  • Do not modify e-cigarette products on your own.
  • E-cigarettes should not be used by teens, young adults, pregnant women, or adults who do not currently use tobacco products.
  • If you vape and have concerns about your health, such as shortness of breath, cough, or chest pain, seek immediate medical care.

Getting burned

Are you someone whose money burns a hole in your pocket? We hope not. But we also hope that you’re not someone whose vaping device burns a hole in your pocket or blows up in your face, hands, or groin. People have shown up at emergency rooms, after vaping devices have blown up, with broken facial bones, severe burns, and extensive lacerations.

Vaping devices exploding and burning is not a frequent occurrence, but it happens. In fact, there were over 2,000 emergency room visits due to vaping devices catching fire or exploding in the period from 2015 to 2017. It’s believed that this statistic is an underestimate and that better surveillance procedures should be implemented to track this problem more accurately. You can see the whole exploding vaping device thing on YouTube. Just search for vaping explosions. Not a pretty sight.

Most vaping explosions happen due to problems with the lithium ion batteries and mechanical mod systems lacking regulators. See Chapter 5 for more information on devices, batteries, why these explosions happen, and what to do to prevent them.

Warning In the event that you do experience a vaping fire or explosion, you should seek immediate medical attention if the burn is more than 3 inches in diameter. Do so also if the burn affects your face, genitals, hands, feet, elbows, or knees and the skin is blackened or severely blistered.

Warning If your clothes catch fire when your vaping device explodes, stop, drop, and roll. And cover your face.

For minor burns, keep the area clean and cover it with a cool compress. Always watch for increasing symptoms of infection, such as redness, swelling, discharge, or fever, and seek medical attention if they occur.

Pregnancy and vaping

If you’re planning on having a baby soon, our strong advice is to stay away from all nicotine products and vaping of any type. We discuss the hazards of smoking associated with pregnancy, as well as the effects on fertility, in Chapter 3. Although vaping may have a somewhat safer profile than smoking regular cigarettes, that does not make it safe — especially when you’re pregnant.

Preliminary research on animals links the possibility of e-cigarette use as a cause of birth defects, especially to craniofacial development. It appears that flavors, especially complex mixtures of flavors, have the largest effect on this anomaly.

Early research suggests that fetuses exposed to nicotine and/or e-cigarette flavors, have a greater risk of brain or lung damage. Like other risk factors, much needs to be determined through further research. In the meantime, keep your baby safe and avoid all vaping.

Seeing seizures

A seizure occurs when there is a sudden surge of electrical activity in the brain, which can cause disturbances in movement, behavior, and consciousness. Signs of a seizure may include staring, confusion, or uncontrolled, jerking movements, as well as memory lapses. Most seizures last from a few seconds to minutes.

Some reports indicate the possibility of seizures having occurred after vaping with e-cigarettes. The FDA has had reports of seizures from people who just started to vape and regular users of vaping devices. It has been postulated that high doses of nicotine could be responsible for these seizures. And seizures are, indeed, one of the known side effects of nicotine poisoning. This effect would, thus, be in response to having overdosed on vaping if, indeed, vaping was the cause of the seizures. However, a causal link has not yet been established.

Warning Some e-cigarettes have very high levels of nicotine. In fact, one e-cigarette, Juul, popular with teenagers has as much nicotine as an entire pack of cigarettes in a single device.

Nicotine poisoning

Nicotine poisoning is relatively uncommon because most smokers and vapers self-regulate their consumption based in part on how they’re feeling. However, emergency rooms and poison control centers have seen an uptick in nicotine poisoning over the past few years with the advent of vaping devices.

E-liquids can contain enough nicotine to kill a small child or pet. Many vapers refill their own devices and maintain a supply of premixed e-liquid formulations or the pure chemicals (including nicotine) that go into mixing the refills. Since 2016, nicotine bottles have been required to come in childproof containers.

Warning You can get nicotine poisoning simply by spilling or touching it while refilling your vaping devices. Always wear protective gloves when handling. It should also go without saying that nicotine products should be kept well out of the reach of children and pets.

Secondhand vapor

What about exposing other people to your vapor? Or what are the risks of being in a room with someone else who’s vaping? The good news is that secondhand vapor is far less toxic than smoke from combustible cigarettes. The bad news is that vaping appears to make the air inside a room lower quality, with small amounts of nicotine and other particles. The health implications of this indoor pollution are unknown.

Encountering the Wild West

E-cigarettes first became commercially available in the United States in 2006. That’s a short time span, and the FDA has been slow to catch up in terms of oversight and regulations. In other words, the industry has been largely on its own until quite recently. That means you don’t have great assurances that products contain what they say and in the amounts that are stated. Furthermore, consumers can’t assume that devices have been made with safe, reliable materials and designs.

New regulatory guidelines are set to come out soon and should provide consumers with more confidence in what they’re purchasing. These directives should help reduce illegal, online sales of fake products as well. You can’t fully assess a product’s safety without knowing exactly what it contains or how it’s manufactured.

Risks of Vaping CBD or THC

In this chapter, we focus on the health risks of vaping nicotine. That’s because this book is intended for those struggling to quit using either tobacco or nicotine. Nicotine is the addictive substance used by vapers who may have the most trouble quitting. By comparison, THC and CBD are less addictive than nicotine. (See Chapter 5 for more information about vaping CBD and THC.)

Vaping CBD

We know of no evidence that vaping CBD has any risk of addiction. On the other hand, there are many claims of health benefits of CBD (see Chapter 5). Unfortunately, many of these claims appear a bit overblown and lack backing by research. At the same time, some benefits have been proven such as treating some severe seizure disorders.

Warning It seems likely to us that at least a few more of these claims will ultimately be proven to have substantiated value. Nonetheless, a risk of turning to CBD is that many of the products are quite expensive and may be less effective than more traditional treatment.

Warning Although CBD has a very low risk profile and is well tolerated at high doses, that doesn’t translate into totally safe. The following problems can occur when vaping CBD:

  • Unreliable quality of the e-liquid, which can contain contaminants due to lack of regulations and oversight, which appears to be tightening.
  • Higher than allowable levels of THC, which is the component of cannabis that produces a high. Most CBD products contain small amounts of THC, but some CBD contains more than it should.
  • Devices that can release particles or metals with unknown risks.
  • Unsafe battery/device combinations that run the risk of fire or explosions.

Tip You can avoid most of the risks associated with vaping by choosing CBD that comes in the form of edibles, lotions, or pills.

Vaping THC

THC produces a high or intoxicated state and can be addictive, though less so than nicotine. In addition to an addiction potential, there are side effects associated with THC, including the following:

  • Slowed reaction times
  • Problems with coordination
  • Feelings of paranoia
  • Red, irritated eyes and dry mouth
  • Memory loss with chronic use

Chronic users of marijuana, including those who vape THC, often have problems maintaining focus and motivation. These issues can have a deleterious effect on school or work. Especially in teens, large amounts of THC may also produce psychiatric problems, such as psychosis, depression, and anxiety. Due to problems with coordination and slowed reaction times, driving can become impaired.

Tip Although THC is illegal at the federal level, it is legal in many states and medical marijuana is legal in even more states. Someone addicted to THC can use the same techniques to quit as discussed throughout this book.

Warning All the same risks cited in the preceding section on vaping CBD apply to vaping THC. Some people purchase THC on the black market. When you do that, you run a substantial risk of receiving a contaminated product. Many of the dramatic headlines in the news concerning vaping leading to serious lung problems and even death, may be due to such contamination (see the “Irritating lungs” section, earlier in this chapter, for more on this issue).

Tip The good thing about THC is that it has an unusually low potential for overdose resulting in death. In fact, at this time, there is only one reported case of a death ostensibly caused by a THC overdose (from vaping). However, some scientists dispute whether THC caused the death.

On the other hand, you could die from an overdose of marijuana containing THC if you happen to be hit by a 400-pound bag of pot dropped on your head from 50 feet.

Evaluating Vaping as a Gateway to Regular Smoking

Numerous critics of e-cigarettes have cited the possibility that vaping may lead many of its adoptees to move on to combustible cigarette smoking. The data say otherwise. For most mature adults, vaping does not lead to the use of regular cigarettes. In fact, many adults are using vaping as a way to decrease or quit smoking entirely.

There are about two million adults who have never smoked but use e-cigarettes. Most of those are young males in their late teens to early 20s. It appears to be rare for them to graduate to regular cigarette smoking. Tweens and teens are another story entirely, and the story is more complicated. (See Chapter 7 for information about adolescents who vape and what happens to them.)