The myth of healthy alternatives to tobacco: Electronic cigarettes are also harmful

Last year, a stressful situation caused Alberto Verdejo, 27, to relapse into his tobacco addiction after a year of not smoking. Four months ago, he started regularly using electronic cigarettes with nicotine to reduce his cigarette consumption, although he had his doubts about the myth of vaping as a healthy alternative to tobacco. At first, he used disposable pods and small devices (about the size of a finger). They offer between 400 and 600 puffs and generally range in price from $6 to $10 (€6 to €10). When one runs out, people can simply throw them away and buy another one. Then, Verdejo switched to using rechargeable ones: "They are cheaper," he explains. The reusable ones are larger and have a tank filled with liquid that can be purchased at specialty stores and smoke shops as well as on the internet. Both varieties can be used with and without nicotine.

Esteve Fernández, Director of the Catalan Institute of Oncology (ICO), and Carlos Rábade, Coordinator of the anti-smoking unit at the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), are adamant in noting that electronic cigarettes and water pipes (shishas or hookahs) are not "healthy alternatives" to traditional tobacco. On the contrary, in many cases, they are a gateway to adolescent nicotine addiction. SEPAR's anti-smoking unit is particularly concerned about vaping devices, especially their use by young people, who see them as harmless. Rábade points out that nicotine takes ten seconds to reach the brain, and adolescents are more likely to develop an addiction to it.

In 2021, 44.3% of Spanish adolescents between 14 and 18 years of age had already tried e-cigarettes at some point, and 22.8% had done so in the last year, according to the Survey on Drug Use in Secondary Education in Spain (ESTUDES). The majority, 60.7%, had used e-cigarettes without nicotine, but that does not make them any less dangerous. The ICO director warns that these products, both with and without nicotine, cause "a certain risk of myocardial infarction." The main difference between electronic nicotine delivery systems (ENDS) and ordinary manufactured cigarettes is that the former lacks a combustion process. Vapor is the product of heating the liquid that vaping devices contain through resistance.

In 2019, only 12.1% of adolescents believed that vaping once a month could be harmful to a person's health, according to a Ministry of Health report on electronic cigarettes, which uses data from the 2019 ESTUDES study but was published this year. There is a similar perception about water pipes. Almost 40% of adolescents attribute little or no risk to smoking tobacco this way, according to a study conducted by Spanish researchers last April.

That research says that one shisha (hookah) session is equivalent to smoking between 25 and 50 traditional cigarettes. Fernandez says that a puff from the hookah has even more carcinogenic substances that can be inhaled than a puff from conventional tobacco products because the intake is longer and deeper in the former. Longer lasting inhalations mean that more substances enter the body. He also warns that the combustion required for this tobacco, which has a special kind of charcoal, can cause carbon monoxide poisoning when done improperly.

As for vaping devices, Rábade warns that they "have fewer harmful substances, but that does not mean that they are less risky than tobacco. In addition to carcinogens, they contain substances such as propylene glycol, glycerin, aldehydes and flavorings, all of which are related to lung irritation and respiratory conditions such as chronic obstructive pulmonary disease (COPD), one of the world's four leading causes of death and disability; COPD causes shortness of breath, coughing, mucus production (sputum) and wheezing. While propylene glycol and glycerin are used harmlessly in many foods and cosmetics, they are harmful when used in combustion, inhaled or sniffed, as is the case with electronic cigarettes.

The inhalation of e-cigarette aerosols causes cardiac arrhythmias and alters ventricular repolarization (a stage of the heart's electrical activity) and heart rate, according to a study conducted on mice published today in the journal Nature. The researchers suggest that the nature and impact of the consequences may depend on the substances that the devices contain, including nicotine, solvents and flavorings. Specifically, they found that menthol-flavored liquids affect atrial conduction (the transport of electrical impulses through the atria of the heart). Several of the effects, including increased heart rate, continued after exposure.

Mexico's Federal Commission for Protection against Health Risks (Cofepris) reported last week that an investigation found that these products contain up to 30 substances beyond what their packaging indicated. The listed ingredients included propylene glycol, glycerin and flavorings. Among the undisclosed elements the examination detected were linalool, an ingredient in insecticides; dimethyl ether, a highly flammable substance used in aerosol paints; benzyl alcohol, which is used in cosmetics, soaps and cleaning products; and ethyl propionate, a component that causes a bad odor in sweat. The Mexican government banned the "circulation and marketing" of electronic cigarettes last May..

Although the best-selling ENDS are rechargeable ones, devices with limited puffs have burst onto the scene over the past year, says Arturo Ribes, the president of the Association of Vaping Promoters and Entrepreneurs. He notes that their popularity partly stems from their ease of use. One need only put the device in one's mouth and inhale; it doesn't even require pushing a button. Estimates say that the industry earned over 100 million euros ($99,638,809) in Spain in 2020; according to a report by the Ministry of Health, there were over a million vaping device users that year.

Esteve Fernández emphasizes that the flavorings added to the liquids, such as the ones that make Verdejo's electronic cigarettes taste like a donut or cheesecake; the aesthetics of the devices, which have flashy and colorful designs; and the social contexts in which e-cigarettes and vaping devices are used all combine to entice young people to use them, as well as to underestimate the health risks they pose. Indeed, a few weeks ago, in the United States, the Juul e-cigarette company was ordered to pay compensatory damages in the amount of $439 million to 33 states and Puerto Rico for deliberately targeting adolescents in its marketing strategy.

A pathology is already associated with using such devices: electronic cigarette or vaping use associated lung injury (EVALI). The disease emerged in the United States in 2019; per the most recent data, there have been 2,668 people affected and 68 deaths, almost all of them in the United States. According to the Centers for Disease Control and Prevention (CDC), symptoms of the disease include cough, shortness of breath and chest pain, as well as fever, chills or weight loss. The disease has only three known cases in Europe: one in Belgium and two in France; the French cases involved American tourists who were visiting the country. EVALI is linked to Vitamin E acetate, an ingredient that may be added to e-cigarette liquids as a thickener, especially the ones that contain tetrahydrocannabinol (THC), a chemical component of cannabis. European legislation prohibits the use of vitamins as an ingredient or additive in liquids, which explains the disease's minimal incidence there.

Although the industry itself touts electronic cigarettes as a tool for quitting smoking, Fernández and Rábade are both categorically opposed to using them. Both experts insist that, far from aiding in smoking cessation, in most cases consumers end up combining ENDS with traditional tobacco. The Ministry of Health also refutes the e-cigarette industry's claims. In its report on electronic cigarettes, the government agency says that the industry's assertion "is incompatible with the current evidence."

Verdejo exemplifies what the doctors say. Using e-cigarettes with nicotine does not calm his anxiety in the same way that typical cigarettes do, so he uses both. "Even if I spend 40 minutes vaping, when I stop, I [still] crave a cigarette because it doesn't satisfy me," he says. When he managed to quit smoking, the only thing that helped were the pills that his doctor prescribed. Both Rábade and Fernández say that pharmacological treatment, combined with support and follow-up therapy, is the only effective way to quit smoking.