Rethinking the Safety of E-Cigarettes in Light of the Vaping Crisis

Although the use of conventional cigarettes has decreased^1,2 in recent years, the popularity of electronic cigarettes (e-cigarettes) has soared. Since 2014, the use of these products, also referred to as vapes, vape pens, e-hookahs, and electronic nicotine delivery systems, has exceeded that of combustible cigarettes among youth and young adults.³ From 2017 to 2018, e-cigarette use among US middle school and high school students increased by 48% and 78%, respectively.⁴

Meanwhile, there has been ongoing controversy regarding the relative safety of one type of cigarette over another, with many survey respondents indicating that they perceive e-cigarettes as less harmful than conventional cigarettes.⁵ However, experts have cautioned that much remains unknown about the effects of these products, and accumulating research shows associations between e-cigarettes and various adverse events, including an increased risk for myocardial infarction that is similar to that of combustible cigarettes.⁶

Other researchers have noted the harmful respiratory effects of various “components unique to flavored e-cigarettes, such as [propylene glycol, vegetable glycerin], and the many different flavoring chemicals, which likely induce respiratory effects not usually observed in cigarette smokers,” according to a paper that explored potential connections between such compounds and asthma.⁷ These components “contain airway irritants and toxicants that have been implicated in the pathogenesis and worsening of lung diseases.”

Emerging animal research supports this notion, including a new study⁸ published that linked several different e-cigarette flavoring agents to increased peripheral airway hyperresponsiveness (P =.02), increased soluble lung collagen (P =.049), and a trend toward increased airway inflammation (P =.089).

Current Vaping-Related Lung Illnesses

These concerns are quickly gaining steam with the escalating reports of severe respiratory illness related to vaping e-cigarettes, including a spate of cases of acute lipoid pneumonia. What began as a handful of reports burgeoned into >200 by the end of August, and >800 cases and at least 11 deaths nationwide by late September.^9,10,11 More than 80% of cases thus far involve youth and young adults, the very demographic that appears to be the main target of companies that sell vaping products, with 62% of cases affecting individuals aged 18 to 34 years and 16% occurring in people <18 years.¹⁰

Most of these patients reported use of e-cigarettes containing tetrahydrocannabinol (THC), whereas others used nicotine-only devices or a combination of the two. A statement from the Centers for Disease Control and Prevention (CDC) noted that no particular substance or device type has been connected with these cases.¹⁰ However, “no consistent evidence of an infectious cause has been discovered. Therefore, the suspected cause is a chemical exposure.”

In a joint statement released in early September, the American Heart Association, the American Lung Association, the American Academy of Pediatrics, and several other organizations supported these efforts and emphasized the need for the US Food and Drug Administration (FDA) to take swift and definitive action to protect consumers from reported risks.⁴ “The FDA must immediately remove all flavored e-cigarettes from the market nationwide, prohibit all marketing to children and prohibit online sales of e-cigarettes,” according to the statement. “The agency also must enforce the law by prohibiting the introduction of new e-cigarette products without prior agency review and authorization and promptly reviewing products already on the market.”