Wednesday 11 December 2019

Professor Luke O'Neill: 'Vape safety now a burning issue'

They are used as an effective way to stop smoking but are e-cigarettes really risk-free, asks Professor Luke O'Neill

Vaping. Stock picture
Vaping. Stock picture

Professor Luke O'Neill

Vaping has been getting something of a bad press of late. Countries worldwide are considering restrictions and bans. Some 39 deaths have been reported in the US and a possible culprit is something called vitamin E acetate. But how dangerous is vaping and if it is banned won't that keep more people on the much more dangerous cigarettes? And why is Donald Trump back-tracking on a ban of flavoured e-cigarettes?

Vaping is done with an electronic cigarette, also known as an e-cigarette, which is a battery powered vaporiser that simulates smoking. When you're addicted to the dreaded weed it's not just the nicotine you need. You also like the habit of putting something in your mouth with your hand and the puffing out smoke. A friend of mine who was a heavy smoker said he liked "visualising his breath". He had it bad. Vaping allows for these sensations but without burning tobacco. The user inhales a vapour made from a liquid that contains chemicals with names like propylene glycol, glycerin, formaldehyde and heavy metals but also flavourings and the all-important nicotine. There are vaping products that have flavourings but no nicotine that teenagers can use for fun.

Since their entrance to the market in 2003, vaping has become big business. About 95pc of e-cigarettes are made in China. There are at least 466 brands with global sales of around $7bn (€6.4bn). The H Ireland Survey (2018) reported that 4pc of the Irish population currently use e-cigarettes and a further 12pc of the population have tried them at some point. About 9pc of current smokers use e-cigarettes, with 10pc of ex-smokers using them. Most people use e-cigarettes to help them quit smoking, though a large proportion use them for fun.

So what's in them? On average there are 42 chemicals in the liquid you vape, and some of these might indeed be cancer-causing, but that is yet to be shown definitively. This contrasts to cigarettes which have 7,000 chemicals, 70 of which can cause cancer. Smoking cigarettes is therefore considered much more dangerous than vaping.

There is evidence vaping may help people quit smoking, although they have not been proven to be more effective than smoking cessation medicines of which there are several, some of which can improve your chances of giving up smoking 1.6 fold. About 70pc of smokers would like to quit smoking, and 50pc report having made a quit attempt in the past year. Smoking is the leading preventable cause of death worldwide. One way to quit might indeed be e-cigarettes and they are much safer than smoking tobacco. They are therefore viewed as the 'lesser of two evils'.

More research is needed to understand the long-term health risks of vaping. One chemical in some e-cigarette flavourings is a buttery-flavoured one called diacetyl, which has been linked to a serious lung disease known as popcorn lung. It was first seen in people working in a microwave popcorn factory who got sick with serious lung problems from breathing in diacetyl. It was being used to flavour popcorn. It can scar the tiny air sacs in your lungs giving you a dry cough that won't go away. Popcorn companies have stopped using it and the good news is diacetyl was banned in e-cigarette liquid under the EU Tobacco Products Directive (TPD) in 2016. Doctors are still keeping a look out for popcorn lung among vapers, especially teenagers.

There are also concerns that non-smokers and children who use flavoured liquids may actually move on to vaping nicotine and become addicted to that, or even take up smoking. The US health secretary has warned: "An entire generation of children risk becoming addicted to nicotine."

If all that isn't concerning enough, vaping's image has recently got worse. In the US, a new lung disease has been reported, called EVALI, which stands for 'Electronic-cigarette (e-cigarette), or VAping, product use-associated Lung Injury' with 39 deaths. Mind you this contrasts with the 8m people who die of smoking-related illnesses every year world-wide. As of November 5, 2,051 patients with EVALI have been reported. I recently visited a hospital in Chicago where there were 19 people with EVALI including an 85-year-old woman.

The big question is what is causing EVALI? This became something of a detective story. The first clue came when it was found that 86pc of the 867 people studied who became ill had vaped liquid cannabis-related products in the previous three months. All had bought these products on the black market. The hunt for the culprit turned to a chemical called vitamin E acetate as the smoking gun. It is found in a cannabis product called THC oil. It has reportedly been used as a cheap cutting or thickening agent by illicit cannabis suppliers. Fluid from the lungs of 29 patients with EVALI were analysed and vitamin E acetate was found in all patient samples. It is sticky, like honey, and clings to lung tissue, possibly causing the damage. The lungs of EVALI patients look like the chemical burns suffered by soldiers attacked with mustard gas in World War I.

Although vitamin E acetate is safe when used in skin creams and as a dietary supplement, research indicates that it could be harmful when inhaled. The outbreak has revealed a huge unregulated marketplace of bootleg vaping products that are essentially a witch's brew of chemicals, sold by unknown manufacturers and sellers.

People are being advised not to use e-cigarettes containing THC, especially those obtained on the black market, until more is known about vitamin E acetate and lung health. It is important that vitamin E acetate not be added to e-cigarette, or vaping, products.

Experience tells us that prohibition is not the answer. This would push vaping underground leaving people exposed to unregulated products. We need to weigh up pros and cons and assess whether vaping helps people give up cigarettes.

Juul Labs, the biggest e-cigarette maker, recently announced a flavour ban for vaping products used by teenagers. Donald Trump was to announce a law to protect young people and raise the age limit for sales of e-cigarettes. He has also said he will ban the sale of most flavoured e-cigarettes as vaping among young people continued to rise. The first lady, Melania Trump, has become involved. "She's got a son," Mr Trump noted, referring to their teenager, Barron. "She feels very strongly about it."

But recently, under pressure from his political advisers Mr Trump hesitated. This is similar to his stance on gun legislation. Some of his advisers believe he should try to win back suburban women, including mothers of teenagers, who worry about their children becoming addicted to nicotine. Other advisers feel that taking away the right to smoke or vape would be something akin to taking away firearms.

Whatever happens in the US, vaping is becoming more common in Ireland. People should be informed of the risks vaping might pose and vaping products must be regulated so as to minimise the risk. After all no one wants to end up with popcorn lung or EVALI now do they?

Luke O'Neill is Professor of Biochemistry in the School of Biochemistry and Immunology at Trinity College Dublin

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