Is Vaping Bad For You? Is It Safe? Experts Weigh In

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Jonathan Foulds

Professor of Public Health Sciences and Psychiatry at Penn State College of Medicine

Electronic cigarettes have been widely available for less than ten years and so, unlike cigarettes, data on their long term effects is not available. However, we can estimate their harmfulness relative to smoking tobacco by comparing the amount of toxic chemicals in e-cig vapor with that in cigarette smoke. Cigarette smoke contains thousands of chemicals, including dozens of known carcinogens. Electronic cigarette vapor typically contains a handful of chemicals and although these are unlikely to be harmless, the ones suspected of potential harm are generally at much lower levels than found in cigarette smoke.

Another way to compare potential harmfulness is to examine biomarkers in the body fluids of people who use different products. A few recent studies have examined the concentration of toxicants in the urine of vapers and compared this with the concentration of toxicants in the urine of cigarette smokers. A study by Hecht and colleagues at University of Minnesota compared 28 e-cig users (various e-cig brands) who had not smoked for over 2 months with over 200 cigarette smokers, and examined the concentration of 6 markers of carcinogenic toxicants. The e-cig users had much lower levels of harmful toxicants in their urine than the smokers, and, in fact, their levels were no greater than never tobacco users. More recently,Goniewicz and colleagues at Roswell Park Cancer Institute measured 13 biomarkers of major carcinogens and toxicants in 20 cigarette smokers who then tried to completely switch to a single brand of e-cigs for 2 weeks. About half the participants completely switched and half continued to smoke at a much lower level while using the e-cigs. The levels of 13 harmful toxicants fell significantly within two weeks of switching from cigarettes to e-cigs.

These studies demonstrate that switching from cigarettes to e-cigs dramatically and quickly reduces exposure to numerous harmful toxicants, including known carcinogens. It is evidence like this that prompted an international panel of experts to estimate that use of e-cigs is likely to be around 95% less harmful than smoking cigarettes. E-cigs deliver nicotine and so can be addictive, although the evidence to date suggests that most e-cigs deliver less nicotine and are less addictive than cigarettes. Nicotine is not carcinogenic but it is not harmless, and, for example, is harmful to the unborn fetus if absorbed during pregnancy. So non-smokers should not start using e-cigs. But it is clear that switching from cigarettes to e-cigs is likely to reduce the risk of serious disease and premature death.

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Jeff Stier

Senior Fellow and Head of the Risk Analysis Division at the National Center for Public Policy Research

Yes, vaping is safer than smoking. E-cigarettes are a life-saving innovation which help adult smokers quit smoking cigarettes.

According to Public Health England, which conducted the most comprehensive review ever done on the topic, e-cigarettes are 95 percent less harmful than cigarettes.

England's Royal College of Physicians (RCP) recommended on April 28th that doctors "promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK."

Yet in the U.S., new FDA regulations will obliterate chances of smokers using e-cigarettes to quit. Meanwhile, leading public health groups including the American Heart Association, the American Lung Association and the American Cancer Society are actively lobbying against e-cigarettes and distorting the science about both the safety of e-cigarettes and how they can help cigarette smokers dramatically reduce their risk, as the RCP put it, by providing, "nicotine without the smoke."

Professor Michael Russell, whose research was the foundation for the 1988 U.S. Surgeon General's report on nicotine addiction, put it simply, "People smoke for nicotine but they die from the tar."

Yet anti-e-cigarette activists cavalierly claim that it will take decades to know whether e-cigarettes are less harmful than smoking. But we know a great deal about why cigarette smoking is so dangerous. It has a lot to do with the combustion of tobacco. We also know a tremendous amount about e-cigarettes, the liquid that goes into them, and what comes out of them when used. Are they "safe?" No. But not much is. Yet there's no question that they are dramatically less harmful than the most dangerous, widely used consumer product ever invented.

By sowing doubt about the lower risk of e-cigarettes, activists unwittingly give smokers the last thing they need: another excuse not to quit smoking.

Every time you see a former smoker using an e-cigarette, you are seeing the life-saving answer to the problem posed by Professor Russell's observation: How can we help smokers who can't or won't quit using nicotine?

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Thomas J. Glynn

Consulting Professor in the Stanford Prevention Research Center at Stanford University School of Medicine

Vaping is a considerably safer alternative to continuing to smoke Public Health Enemy Number One, the burned (or combusted) cigarette, which kills nearly one-half million Americans every year.

That said, there are a number of important caveats to this statement.

First, all vaping products are not equal - the term "vaping" encompasses a wide range of products, used in many different forms, and with dizzyingly different ingredients.

Second, to say that vaping is safer than cigarette smoking – which is accurate, based on all data to date – does not mean that vaping is entirely safe. For example, long-term nicotine use is associated with increased risk of heart disease in some people, and children and adolescents and women who are pregnant should not be exposed to nicotine. Further, while data clearly suggest that short-term vaping is far safer than continuing to smoke cigarettes, no data are yet available regarding the health implications of long-term use of vaping products.

Third, just because vaping is safer than smoking cigarettes does not mean that it is a good thing to do. While many vapers report pleasant camaraderie while vaping with others, there is no health reason to vape except as a means of aiding an effort to quit smoking cigarettes.

Finally, concerns have also been raised regarding the potential for youth who vape to go on to use combusted cigarettes. There is a risk of "re-normalizing" cigarette smoking after years of progress in reducing cigarette use, and the emergence of "dual users", i.e., cigarette smokers who do not use vaping products to quit cigarette use but, instead, use these products to continue to smoke and vaping only in places where cigarette smoking is not permitted.

Nevertheless, there is significant potential for vaping to contribute to the decline of combusted cigarette use. Data to date suggest that vaping as a means of quitting smoking may be about as effective in helping smokers quit as the six FDA-approved quit smoking medications (i.e., nicotine gum, patch, inhaler, and nasal spray, and bupropion and varenicline), although most U.S. medical organizations recommend using one or more of the FDA-approved medications before trying vaping as a means of quitting, since the FDA medications have been widely tested, proven safe when used as directed, and have known effectiveness profiles.

The bottom line is that vaping is certainly safer than cigarette smoking (two UK organizations – Public Health England and the Royal College of Physicians, have argued that vaping is as much as 95% safer than smoking cigarettes). Since cigarette smoking continues to exact a horrendous toll in the U.S. – the aforementioned half-millions deaths per year, many millions sickened every day, children exposed to secondhand smoke, and an annual cost to the economy of more than $300 billion in health care costs and lost productivity – any action, including vaping, which can help the nation's 40+ million cigarette smokers to stop will be a great step forward for public health in the U.S.

Vaping Is Bad For Your Health

Highlights:

• "Listening to some e-cigarette advocates you would think that vaping was no more dangerous than inhaling purified water vapor. However, there is nothing natural about deeply inhaling a mist of propylene glycol and/or glycerin deeply into the lungs on a daily basis for years. The vaporization process involves a heating element which, especially in higher -powered advanced vaporizers, produces formaldehyde - a known carcinogen. Almost all e-juice flavors contain aldehydes, ketones, and natural extracts, which are felt to be safe when ingested. Nevertheless, the toxicity spectrum of the lung is very different from that of the gut. Many flavors, especially sweet and creamy flavors, contain diacetyl compounds which, when inhaled, are known to be a cause of serious lung disease among flavor manufacturing workers."

  - Robert K. Jackler, M.D. // Principal Investigator, Stanford Research Into the Impact of Tobacco Advertising, Stanford University School of Medicine

• "Big Tobacco and its allies have been trying to obscure the emerging science on the dangers e-cigarettes pose to public health. But claims that "vaping" is a healthier alternative to cigarettes, instead of a gateway, were disproven by a recent American Journal of Public Health study that found smokers who have used e-cigarettes are less likely to cut back on cigarettes in the future than smokers who haven't used them."

  - Larry Cohen // Founder & Executive Director of the Prevention Institute

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Matthew L. Myers

President of the Campaign for Tobacco-Free Kids

Electronic cigarettes could benefit public health if:

• they are properly regulated;
• found to be effective at helping smokers quit completely; and
• are responsibly marketed to adult smokers.

In any event, they are not safe, especially for kids. Kids should not use any tobacco products, including e-cigarettes. Unfortunately, youth use of e-cigarettes in the United States has skyrocketed in recent years. The CDC's latest survey showed that almost one-quarter of all high school students were current (past-month) users of e-cigarettes in 2015, compared to 10.8 percent who smoked regular cigarettes. That trend is not surprising as e-cigarettes have been irresponsibly marketed using tactics long used to promote regular cigarettes to kids and are sold in an assortment of kid-friendly flavors such as gummy bear and cotton candy.

E-cigarette use can put kids at risk of nicotine addiction. The CDC has warned that nicotine exposure could also harm adolescent brain development and lead to sustained tobacco use. Some studies have also found other harmful or potentially harmful chemicals and toxins in some e-cigarettes, even if at lower levels than cigarettes. Further, while some of the flavorings used in e-cigarettes might be safe for ingestion, they are not necessarily safe when inhaled. Researchers have raised concerns that the chemical flavorings found in some e-cigarettes and e-liquids could cause respiratory damage. Our kids should not be the guinea pigs while we learn more about the health effects of e-cigarettes.

As for the impact on current smokers, the evidence to date in the U.S. is limited and inconclusive as to whether e-cigarettes are effective at helping smokers quit. The CDC has reported that three out of four adult e-cigarette users are also cigarette smokers. The U.S. Preventive Services Task Force recently conducted a thorough evaluation of the science and concluded that "the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation..." Without regulation, manufacturers have produced many e-cigarette products that don't help smokers quit and frustrate those who try to use them to quit.

The Food and Drug Administration recently issued long-overdue regulations for e-cigarettes that prohibit sales to children under 18 and will help answer the many questions about these products. Under these rules, the FDA will be able to learn about the contents and health effects of e-cigarettes and evaluate the evidence whether these products can help smokers quit. Effective regulation by the FDA is critical to minimizing the risks posed by e-cigarettes and maximizing the potential benefits.

• Robert TarranAssociate Professor at the University of North Carolina at Chapel Hill School of Medicine
• Robert K. JacklerPrincipal Investigator of the Stanford Research Into the Impact of Tobacco Advertising Program, and Sewall Professor and Chair of the Department of Otolaryngology-Head & Neck Surgery at the Stanford University School of Medicine
• Lena D. MatthiasTobacco-Free Environment Coordinator and Master Certified Tobacco Treatment Specialist at University of Michigan
• Larry CohenFounder and Executive Director of Prevention Institute
• Larry N. WilliamsAssistant Professor in the College of Dental Medicine at Midwestern University, and Member of the Academy of General Dentistry
• Matthew L. MyersPresident of the Campaign for Tobacco-Free Kids

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Robert Tarran

Associate Professor at the University of North Carolina at Chapel Hill School of Medicine

This is a new field and evidence is still emerging. However, perhaps the most compelling data on e-cigarettes has come out of the TCORS program that I direct at UNC. Researchers in this program looked for changes in gene expression in the upper airways of control subjects, heathy smokers and e-cig vapers. Startlingly, they found that more genes were changed in the airways of vapers than of smokers. Furthermore, most of the genes that were changed were consistent with immunosuppression. Whilst additional studies will need to be confirmed, this means that vapers will probably be more prone to respiratory infections.

In the pharmaceutical industry, any drug that is used for human consumption has to undergo extensive toxicological testing before a series of clinical trials before it can be considered safe to use. To the best of my knowledge, e-liquids have not undergone any such testing, which to me is a major cause of concern. Given that the vaping industry is a multi-billion dollar industry, it seems reasonable that they should foot the bill to ensure that their compounds are safe. While, the constituents of e-liquids (e.g., propylene glycol, vegetable glycerin and flavors are on the GRAS (generally regarded as safe) list, GRAS compounds have only been tested for safety following oral ingestion little is known about their safety following inhalation. As a case in point, diacetyl, a butter flavor that is used in popcorn amongst other things, and has been shown to be present in e-liquids (2) causes bronchiolitis obliterans, deadly destruction of the lung, when inhaled.

Irrespective of the above comments, nicotine is a highly addictive compound that is toxic at high doses. People smoke and/or vape to get nicotine to the brain. The number of young people who vape has been dramatically increasing. However, in adolescents, nicotine exposure alters the development of the brain and changes how neurons connect: it lowers the threshold for addiction in adults. That is, developing young people who smoke will have permanently changed their brains in such a way as to increase their nicotine craving as adults.

The Jury's Still Out

Highlights:

• "Vaping exclusively (without smoking any cigarettes) is almost certainly less harmful than continuing to smoke conventional tobacco cigarettes, though the data to prove this hypothesis do not yet exist because e- cigs are such new products that entered the market without regulation (until very recently)."

  - Nancy A. Rigotti, M.D. // Director of the Tobacco Research and Treatment Center at Massachusetts General Hospital & Professor of Medicine at Harvard Medical School

• "The safety of vaping is not well established. There is no evidence showing that vaping is safe and that it does not have any significant health effects. No well-controlled short-term or long-term studies have been conducted to evaluate the health effects of vaping. While the results of some early studies have suggested that some of the acute cardiovascular and respiratory effects seen with smoking and not seen with vaping, it is unclear whether the health risks associated with repeated and frequent vaping are minimal."

  - Aruni Bhatnagar, Ph.D. // Smith and Lucille Gibson Chair in Medicine, University of Louisville

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Laurent Huber

Executive Director of Action on Smoking and Health (ASH) and FCA Ambassador at Framework Convention Alliance (FCA) for Tobacco Control

Combustible tobacco products like cigarettes are extremely toxic, killing approximately 6 million people per year. Given that cigarettes are so ridiculously toxic, vaping has the potential of being less harmful. For a smoker who cannot overcome nicotine addiction, even using approved pharmaceutical and other therapies, vaping is likely to be a better alternative than continuing to smoke cigarettes.

However, the scientific community is only beginning to look into the long term impact of vaping on health and, because there are so many vaping products on the market it is difficult to make a blanket statement about the safety of all vaping devices. Some researchers in the public health arena are concerned about claims that vaping is 95% safer than smoking cigarettes, noting that those claims are educated guesses at best. And while vaping may be safer than using combustibles, this does not imply they are a hundred percent safe.

Nicotine is not benign, and even if it was, addiction itself harms an individual, even if that harm is solely financial. It is immoral for any person or corporation to profit from causing someone's lifetime addiction.

For this reason, the role of the tobacco industry in this debate is a bit worrisome. A number of corporations that in the past focused on selling cigarettes are now marketing and selling the entire gamut of nicotine delivery products, including traditional combustible products such as cigarettes, various forms of oral tobacco, alternative nicotine delivery products such as e-cigarettes, and products that are intended to assist with cessation such as NRTs. While it would be useful for addicted smokers who cannot quit to have access to safer nicotine delivery products, it would not be ethical or good for overall public health to flood the market with vaping devices that could increase the prevalence of nicotine addiction among current non-smokers and future generations.

It is clear that vaping can have potentially both positive and negative impacts on public health. Policy should seek to mitigate the negatives and enhance the positives, and the public health community needs to have a robust discussion on how to accomplish this. Strong anti- or pro-vaping positions in the public health community make this dialogue more difficult, but from following these debates, I recognize that views from both sides come from a sincere desire to avoid harm.

In determining policy, governments and the public health community should consider the following:

1. Policy should be based on science (both medical and epidemiological) in order to determine the safety of the product, its effectiveness as a cessation tool, and its impact on nicotine initiation.
2. Including vaping restrictions in most smoke free policies makes sense.
3. The marketing of vaping products to non-smokers is problematic and should be addressed. Children should not be targeted, including with candy flavors, and restrictions similar to those for combustible tobacco products should be put in place. Initiation to nicotine is not good for public health, and corporations' intent to addict next generations to nicotine is unethical, even if the delivery mechanism is safer than combustibles.
4. The burden of proof for health claims should be borne by manufacturers of vaping devices.

• Nancy A. RigottiProfessor of Medicine at Harvard Medical School and Director of the Tobacco Research and Treatment Center at Massachusetts General Hospital
• Aruni BhatnagarProfessor and Smith and Lucille Gibson Chair in Medicine at University of Louisville
• Laurent HuberExecutive Director of Action on Smoking and Health (ASH) and FCA Ambassador at Framework Convention Alliance (FCA) for Tobacco Control

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Nancy A. Rigotti

Professor of Medicine at Harvard Medical School and Director of the Tobacco Research and Treatment Center at Massachusetts General Hospital

I don't have a side to pick. My answer is: We don't know.

Vaping exclusively (without smoking any cigarettes) is almost certainly less harmful than continuing to smoke conventional tobacco cigarettes, though the data to prove this hypothesis do not yet exist because e-cigs are such new products that entered the market without regulation (until very recently). However, most people using e-cigs appear to be continuing to smoke some cigarettes, often to reduce harm. It is not clear how much (if any) harm reduction results from this dual use. Finally, we are still learning what, if any, new risks the contents of e-cigs or process of vaping might produce. If harmful, how harmful vaping itself is depends on how long it is done. A smoker who switches totally to e-cigs for a short term and then quits vaping probably runs very little risk from vaping even if vaping has some inherent risk. If vaping has any risks, it will be larger for individuals who vape indefinitely, of course. And risk will be even higher for those who continue to smoke cigarettes while also vaping.

Image: Jennifer Borton / iStock.