Tuesday, November 5, 2019

Vaping - what we know and what we don't

Some 70 years after Doll and Hill published their landmark paper in the British Medical Journal linking smoking to lung cancer, we know a lot more about both the dangers of cigarettes and the predatory practices of the tobacco industry. A major public health campaign that included both education and regulation has led to decreased smoking and a corresponding drop in coronary disease. We still need on-going efforts, as the effects can be overcome by tobacco advertising. Banning flavored cigarettes or restricting their sale was shown to work in a study comparing youth smoking in Lowell, which had such a restriction beginning in 2016 and Malden, which did not. The consequences of smoking are still a huge problem in China and in many developing countries where tobacco ads dwarf public health measures, so we must stay vigilant.

The new epidemic which requires action is the use of e-cigarettes, or “vaping.” Vaping is the act of inhaling the aerosol produced by a battery-powered device. E-cigarettes contain pre-filled pods of liquids that the user adds to the device, and now are most commonly small devices that resemble a USB stick, and so are easy to carry and use. The liquids generally consist of glycerin, water, propylene glycol, nicotine and flavorings. Juul, by far the leading seller of e-cigarettes, has claimed that they are selling their product as a smoking cessation aid, and prominently feature adult smokers extolling the value of the product for this purpose. However, they clearly market to youth on social media, and by far the biggest selling products are those that are flavored. Flavor was the reason that about a third of users first tried e-cigs and most (63%) current users used flavors other than tobacco. Fruit flavors were most likely to motivate young adults to try vaping. In 2018, two thirds of U.S. middle and high school students had tried e-cigarettes or been exposed to second-hand aerosol in the previous 30 days. E-cigarette use is also a strong gateway to use of tobacco cigarettes among youth, with over 4-fold greater smoking among e-cig users.

Are e-cigarettes safer than combustibles? Clearly smoking causes cancer. Mint- and menthol-flavored e-cigarettes have very high levels of pulegone, a known carcinogen. E-cigarette smoke has also been shown to induce cancerous changes in the lung and bladder of mice. Smoking is a major contributor to coronary disease. What about e-cigarettes? They are associated with an increased risk of myocardial infarction that is similar to that of smoking conventional cigarettes, and dual use is riskier than using either product alone. Many women use e-cigarettes while they are pregnant, perhaps believing that they are safer than combustibles, but e-cig use has been shown to delay implantation and cause reduced weight gain of the fetus. While some short-term studies have shown minor improvements in measures of lung function among COPD patients who switched from combustible to e-cigarettes, vaping has been clearly shown to cause airway inflammation and lung disease. Finally, our dental colleagues have reported that e-cigarette aerosols increase the risk of cavities similarly to gelatinous candies.

Last, but far from least, is the mysterious and frightening epidemic of vaping-related lung disease. This was first reported from the upper Midwest in the spring of this year but has rapidly spread. Vaping-related lung disease has now been reported in 49 states (all but Alaska), DC and the US Virgin Islands. The number of cases is a moving target, but as of Oct 29, 2019, there were 1888 confirmed and probable cases and 37 deaths. The illness consists of early symptoms of nausea, vomiting and abdominal pain, followed by progressive shortness of breath, often leading to respiratory failure and the need for being placed on a ventilator. The chest X-ray shows diffuse infiltrates. The exact cause is still controversial. Among patients with full data, 86% reported use of THC-containing products, 64% nicotine-containing products and 52% both. No single compound has been shown to be the cause. The majority of those affected have been teens and young adults, though the death rate has been higher in middle-aged and older victims. Because the cause remains unknown, the CDC recommends against the use of any vaping products.

The bottom line: vaping is NOT safe, and best avoided.

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