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Dr. Brett Belchetz Headshot

The Unadvertised Health Risks of E-Cigarettes

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In just a few short years, e-cigarettes have grown from an obscure, mostly unknown product into a booming industry across North America. While retail sales data in Canada is hard to come by, sales in the United States have exploded from a mere $80 million (USD) in 2010 to $1.7 billion (USD) in 2014, an over 2000% increase in only 4 years. A 2015 survey in Canada found that 15% of all Canadians and 20% of Canadian youth have tried, or are actively using e-cigarettes. Contrasting these numbers with Canada's rate of traditional tobacco cigarette smoking, which stands at just 16%, demonstrates just how mainstream the use of e-cigarettes has become.

This drastic growth rate has left governments scrambling to create new legislation to regulate these products. With no existing laws addressing where e-cigarettes can be consumed, or where and to whom they can be sold, the current situation has been described as akin to a "Wild West' by prominent figures in health and education, where anyone - even minors - can purchase e-cigarettes and use them in nearly any setting, including public spaces where the smoking of tobacco cigarettes is forbidden. Laws such as Ontario's Making Healthier Choices Act, which on January 1, 2016, will place similar restrictions on e-cigarettes to those that exist for tobacco cigarettes, are quickly becoming the new norm -- usually over the strident objections of the e-cigarette industry and its proponents.

So what exactly are e-cigarettes and how safe are they?

All e-cigarettes have the same basic components -- a battery, a heating element, and a cartridge that is usually filled with a combination of nicotine, flavouring, and a liquid such as glycerin or propylene glycol. When the battery activates the heating element, the liquid inside is vaporized, creating a fog, which is very similar to that seen at rock concerts. It is this fog that users inhale and exhale, rather than smoke from combustion as is produced by tobacco cigarettes. While nicotine e-cigarettes are technically illegal in Canada, nicotine cartridges for e-cigarettes are sold extensively "under the counter" in stores across the country.

Several primary questions over the safety of e-cigarettes have been raised by those in health circles. First, no data exists as to the long-term effects on human health of breathing e-cigarette vapour. While glycerin and propylene glycol are approved for oral consumption, no studies have been performed to measure the effects of their chronic, repetitive inhalation into the lungs, and medical science is replete with examples of substances that, while safe for the GI tract, are extremely hazardous to our lungs. Second, there are concerns that the vaporization process used by e-cigarettes might generate harmful chemicals such as formaldehyde, with potentially severe resulting health risks. A third, oft stated concern, especially among public health experts, is that the acceptance of e-cigarettes, especially in previously off limit public spaces, may lead to a re-normalization of smoking behaviours, particularly among youth, risking a reversal of decades long trends of decreasing smoking rates.

The e-cigarette -- or "vaping" -- industry and its proponents have disputed these worries, often quoting a 2014 study by the Harvard School of Public Health that found that only 1 per cent of non-smokers had ever tried an e-cigarette. Concluding from this data that the vast majority of "vapers" are those that are already smoking tobacco cigarettes, the industry argues that there is no possibility that e-cigarettes could be more dangerous than the tobacco cigarettes that they replace, and that they are a valuable tool in the war to reduce traditional cigarette use. To quote a prominent pro e-cigarette web site: "they cannot be as harmful as cigarettes, since with cigarettes, it is the mode of nicotine delivery...that is responsible for most of the disease."

However, recent data from two new studies raises serious concerns with respect to the industry's assertions of e-cigarettes' absolute safety versus tobacco cigarettes.

In a study published in January by the New England Journal of Medicine, researchers found that e-cigarettes powered at higher voltages actually produced up to 15 times more formaldehyde than a tobacco cigarette, resulting in a 5 times greater cancer risk versus traditional cigarette smoking. Despite the vocal objections of the industry that the 5-volt setting used in this study did not represent real world use of these products, most adjustable voltage e-cigarettes generate power levels of up to 6-volts, placing this setting well within their operating parameters.

And in February of this year, the Johns Hopkins School of Public Health published a laboratory study of the effects of inhaled e-cigarette vapour on the ability of mice to withstand bacterial and viral infections. Their ominous finding: "The mice exposed to e-cigarette vapour were significantly more likely to develop compromised immune responses to both the virus and the bacteria, which in some cases killed the mice"

Similarly, there is a growing body of recent data to suggest that e-cigarettes do act as a strong gateway to traditional cigarette smoking for young non-smokers. A study published in February by the University of Michigan, of 40,000 US teenagers, found that among 14 year olds, 8.7 per cent had tried an e-cigarette while only 4 per cent had ever tried a tobacco cigarette -- meaning that, in direct contradiction of the previous 2014 Harvard study, the majority of e-cigarette using teens had never smoked before. Even more worrisome, the CHETS study from Wales, UK, published in late 2014, found that 6 per cent of 10 year olds they surveyed had tried e-cigarettes, compared to only 2 per cent that had tried tobacco, and that children who had tried e-cigarettes were 7 times more likely to state they might start smoking tobacco cigarettes within 2 years versus children that had never smoked at all.

So when no evidence exists to show that e-cigarettes are safe for long-term use by humans, when laboratory studies demonstrate worrisome potential physiological risks, and when strong evidence is mounting that e-cigarettes are leading our youth to consider smoking tobacco cigarettes, I would contend that caution here is the only reasonable approach. Laws such as Ontario's, that will prevent minors from purchasing these products and also protect bystanders from inhalation of second hand vapour, are a common sense first step, and one that will hopefully be extended across the country in short order. The alternative -- blind acceptance of a potentially dangerous new product, and a possible reversal in decades of hard won success in reducing tobacco cigarette use -- is just too frightening to allow.

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