Electronic Cigarette Side Effects ∣ Stop Vaping Now

I am writing this article as a concerned parent of teenagers and a doctor who doesn’t know enough about the subject.

After watching a TED talk, which I’ve included in the summary, my partner asked me to write a post on vaping. Basically, to investigate the claims made so we can decide ourselves.

My patients believe that vaping is healthier than smoking. Taking a medical history involves asking about habits.

“When I ask, “Do you smoke?” I often get the answer, “I have never touched a cigarette in my life; I only vape.”

From a medical standpoint, it cannot logically be healthy. However, the focus is still on traditional cigarettes.

This is a topic that I have had to research. My reading confirms that electronic cigarette side effects exist and are scary.

“I can only imagine what lies in the future for vapers, many of whom are only teens with 80% of their lives ahead of them.”

“Cigarette smoking became an epidemic between 1880 and 1900, and it took ≈50 years before the connection between tobacco smoking and the multitude of smoking-related diseases became clear.”

Wold L et al. ⁴

Disabling diseases such as emphysema, cancer, and heart failure develop after decades of exposure; we do not have the proof yet.

“The summary of my reading is this. No one should be vaping. Not smokers wanting to quit, and definitely not smoking-naive teenagers wanting to be cool or feel high.”

Three factors make it difficult to assess e-cigarette safety:

• the sheer number of devices,
• the variable composition of 15,000 available e-liquids, and
• the fact that many users don’t limit themselves to one device or e-liquid. ²

Despite this, my research confirmed significant evidence of harm, not only to the lungs but also to other organs. ²

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What does an e-cigarette device consist of?

Although the devices vary, the components are the same:

• A chamber with the e-liquid
• A power source
• A heating element
• A mouthpiece

The term vaping is misleading. We immediately think of water vapor. Water is pure and harmless.

Electronic cigarettes form an aerosol.

Vapor definition: A substance converted into a pure gaseous state.

Aerosol definition: A system of colloidal insoluble particles dispensed in a gas or vapor.

The aerosol in an e-cigarette is a gas form of its base plus the additives. The base is usually propylene glycerol (PG) and/or glycerin. ⁶ This is the carrier for additives:

• nicotine,
• flavors, and sometimes
• tetrahydrocannabinol (THC).

Ethanol is in many e-liquids in varying concentrations but is usually not listed as an ingredient. ¹³

Analysis of e-liquids and their aerosols also found:

• formaldehyde,
• acetaldehyde,
• acetoin,
• diacetyl,
• carbonyl,
• volatile organic compounds (VOCs, such as benzene and toluene),
• nanoparticles,
• trace metal elements,
• polyaromatic hydrocarbons,
• bacterial endotoxins, and
• β-glucans. ^{2 ,4}

Vapers are inhaling these substances.

Does it sound safe to you?

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The history of e-cigarettes

The majority of electronic cigarettes contain nicotine; they are also called electronic nicotine delivery systems (ENDS).

They were marketed in 2007 as a healthier alternative to cigarettes in the battle to stop smoking.

• They achieve a better cessation rate than nicotine gum and patches. ¹
• Studies show a higher relapse rate. ¹
• It is not a smoking cure; only 18% in one study stopped indefinitely. ¹

Teens are impulsive, and they love to try new things. They’re also craving independence, and they love to make things their own. E-cigarettes meet these needs perfectly by allowing them the chance to both innovate and personalize their vape experience. They can choose from over 15,000 different e-liquid flavors and multiple nicotine concentrations.

Dr. Krishnan-Sarin

Nicotine-related electronic cigarette side effects

Addiction

It is a fact that nicotine is addictive. Adolescents are more likely to become addicted to nicotine than adults. ⁸

You have to ask yourself if this is the driving factor behind the e-cigarette industry.

“Millions of addicted youth = money.”

Dr Megan C Diaz of the Truth Initiative Schroeder Institute noted in her research that “disposable e-cigarette manufacturers (are) providing consumers with bigger, cheaper disposable e-cigarettes that come in increasingly higher nicotine strengths.”

Ironically, ENDS may lead to increased cigarette use. This is a result of teen nicotine addiction that would not exist if it were not for e-cigarettes, which are viewed as less harmful. ¹²

Nicotine is known to affect many organ systems and cause disease. Many electronic cigarette side effects are because of this.

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Brain effects

Nicotine is a known psychoactive drug. It affects thought processes and can influence emotions in the brain’s prefrontal cortex (PFC). Nicotine reaches the brain after 10 to 20 seconds after inhalation. ⁸

Fact 1: Adolescents are more likely to become addicted to nicotine than adults.

Fact 2: The PFC is still developing and maturing during adolescence. Nicotine may cause permanent remodeling. ⁸

There are long-term effects of nicotine when started in the teenage years:

• Depression and anxiety disorders
• Poor memory
• Decreased concentration
• Antisocial personality disorder
• Learning problems
• Increased susceptibility to other addictions

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Insulin resistance

Nicotine is a predisposing factor for type 2 diabetes, not cigarette smoking itself. Studies show that smokers who stop but continue with nicotine gum remain at risk. ^{9, 14}

This is not a condition you want to trigger at any age, particularly not in childhood. Insulin resistance goes hand in hand with obesity.

There is already an epidemic of obesity in children worldwide. ¹⁵ A fast and processed food generation addicted to mobile phones and online games; increased calorie intake and decreased physical activity.

Overweight teens are vulnerable.

• They are at increased risk for bullying, mental health issues, and low self-esteem.
• They are unlikely to lose weight as adults. Obesity increases the risk of heart disease, high cholesterol, and, as mentioned, diabetes down the line. ¹⁵

“Nicotine addiction will make this a vicious cycle, harder to break.”

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Heart and blood vessel effects

A three-year study evaluated the heart and blood vessel effects of cigarette smokers (nicotine), ENDS users (nicotine), and non-smokers. ⁵

Smoking and vaping had similar negative outcomes.

• Increased heart rate
• Increased blood pressure
• Increased narrowing of arteries
• Poor exercise performance on treadmill stress tests

The most concerning observation about this study is the difference in the average ages and years of nicotine exposure in the smoking and vaping groups.

Study participants	Average age	Average use
Traditional cigarettes users	43 years old	23 years
E-cigarette users	27 years old	4 years

These studies add to the growing body of science that shows similar cardiovascular injury among people who use e-cigarettes and those who smoke combustible cigarettes. Additionally, it shows this cardiovascular risk is seen even among younger people who have a shorter history of nicotine use.

Aruni Bhatnagar, Ph.D., FAHA, Professor of medicine, biochemistry and molecular biology

The relatively short time that ENDS have been in use limits study data. However, there have been other significant studies of the effects on the hearts of adolescents. The American Heart Association (AHA) summarized these in the picture below. There is a lot of medical terminology, but you get the idea: it’s bad. ⁴

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Increased clotting risk

A study was presented in 2021 that showed a significant increase in blood clots 15 minutes after using nicotine-containing e-cigarettes. ^16,17

Twenty-two patients participated on two separate days, at least one week apart. First, taking 30 puffs of the nicotine-containing e-cigarette, then, on the second occasion, 30 puffs of a nicotine-free device as a baseline.

As with other studies, they confirmed that blood pressure and heart rate increased after the ENDS, and blood vessels narrowed temporarily.

It was a small but worrying study. The conclusion was that ENDS users are at increased risk for heart attacks and strokes.

Another study done in 2016 suggested that the ultrafine particles found in cigarette smoke and e-cigarette aerosol activate platelets and might lead to blood clots. The nicotine had a further dose-dependent effect on the clotting. ^18,19

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General electronic cigarette side effects

These are side effects that occur even in zero-nicotine e-cigarettes. All the other components and contaminants cause them.

Mouth health

E-cigarettes cause mouth pain, bleeding gums, and smelly breath.

Aerosols disturb the mouth microbiome and increase gum disease and inflammation in the mouth. ³ Studies have recorded increased cytokines in the saliva of adolescent ENDS users, confirming inflammation. ⁴

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Tooth decay

The results showed

• Four times increase in bacteria sticking to the teeth
• A doubling in the plaque layer
• 27% drop in enamel

With people living into their 80s, we need to look after our teeth.

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Stomach and intestine effects

The GIT side effects are non-specific. ⁹

Common reported inflammatory adverse effects are

• Nausea and vomiting
• Stomach burning
• Changes in bowel movements

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Lung effects

a. Electronic Cigarette and Vaping-Associated Lung Injury: EVALI

There has always been vape-associated lung injury, as you will read. The spike in e-cigarette use around 2019 correlated with more severe lung disease in vapers. Increasing hospitalization and even death, 2500 cases in 5 months. ¹ The number of sick ENDS users with the same presentation made the link possible.

An investigation found that the risk of EVALI was higher when using ENDS that contain THC or CBD, but it also occurred with nicotine-only vaping.

Analysis of the THC-containing e-liquid showed high levels of the additive vitamin E acetate (VEA). VEA thickens the e-liquid. ¹ EVALI cases have decreased since 2019 after identifying THC and VEA as the triggers.

“The lesson here is that you do not know what new chemicals manufacturers add to e-liquids:

• When will the next wave of acute severe lung injury strike?
• What quiet, slow damage is being done that we are unaware of?”

It is always valuable to hear a patient’s story; a 17-year-old speaks out after a double lung transplant due to vaping.

b. Inflammation and scarring

Patients read about EVALI cases dropping and think that vaping-associated lung disease no longer exists.

There have always been and are ongoing cases of lung inflammatory disease. The process is not 100% understood. Doctors see increased inflammatory markers in tissue and blood tests.

I will list eight to make my point, “acute eosinophilic pneumonia, organizing pneumonia, lipoid pneumonia, diffuse alveolar damage and ARDS, diffuse alveolar hemorrhage, hypersensitivity pneumonitis, peribronchiolar granulomatous pneumonitis, and the rare giant-cell interstitial pneumonitis.” ²

Dr. SR Broderick explains in a John Hopkins Medicine post that specialists have also seen increases in lung collapse and bronchiolitis obliterans (OB), also known as popcorn lung. OB is caused by inhaling diacetyl. This is one of the substances used to flavor e-liquid.

The bases, propylene glycol and glycerin, are lung-toxic, even though they are approved food additives. ⁹

In extreme cases, lung damage can mimic toxic inhalation syndromes. We see these symptoms in workplaces such as factories, where employees may come in contact with acids, metals, and solvents. They also occur with accidental inhalation of household cleaning products.

In surveys, teens who vape report increased wheezing and coughing. Studies have also shown that vaping exacerbates asthma. ^1,2

c. Increased infection risk

There is also evidence that the e-liquid aerosol affects the user’s immune response in the lungs. The white blood cells, our immune army, cannot clear bacteria and viruses efficiently. Therefore, infection risk increases. ^1,4

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Cell damage

E-liquid aerosols contain highly reactive free radicals. ⁷

Oxidative stress from free radicals causes cell damage. ^1,4 This can lead to organ dysfunction and cancer after years.

The Cleveland Clinic article ” Why You Should Care About Free Radicals ” explains the process in beautiful and basic language.

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Cancer risk

Nitrosamines are well-known carcinogens in conventional cigarettes (CC). They are also present in the urine of e-cigarette smokers who have never smoked CC. ¹⁰

These trace elements and heavy metals are found in various e-liquids: cadmium, nickel, tin, copper, silver, iron, and chromium. ^9,11 They are known to cause sinus and lung cancer. ⁹

Vape aerosol copper levels are six times higher than conventional cigarette smoke. Copper enhances the DNA damage caused by nitrosamines. ¹⁰

Other carcinogens found in the vaping fluid are formaldehyde, acetone, acetaldehyde, and acrolein. ¹¹

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Australia should be our role model

To protect their youth, the Australian government will stop all imports and sales of non-nicotine-flavored vaping devices in 2024.

This follows existing restrictions. Since 2021, Australians have needed a doctor’s prescription to access e-cigarettes containing nicotine.

According to the World Health Organisation

• About 30 countries have now banned the sale of ENDS.
• Approximately 80 have legislative restrictions on the devices.
• Over 80 nations have no bans or regulations enforced.

“Let us learn from Australia. Governments ban products for legitimate reasons.”

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Summary

• If you are an adult who vapes, I believe that I have proved the point that it is as harmful as smoking.
• For concerned parents of teens, Dr. Tomor gives excellent advice. 1) Empower them to make the decision not to vape with information. Read this post to them, and watch the videos with them. 2) Calculate the cost of vaping with them and quantify it with something else they value.

“In 30 years, maybe we will discover that electronic cigarette side effects are more harmful than those of smoking.”

This is the TED talk that triggered this post.

References

1. O’Callaghan M, Boyle N, Fabre A, Keane MP, McCarthy C. Vaping-Associated Lung Injury: A Review. Medicina (Kaunas). 2022 Mar 10;58(3):412. doi: 10.3390/medicina58030412. PMID: 35334588; PMCID: PMC8949983. https://www.mdpi.com/1648-9144/58/3/412
2. Park JA, Crotty Alexander LE, Christiani DC. Vaping and Lung Inflammation and Injury. Annu Rev Physiol. 2022 Feb 10;84:611-629. doi: 10.1146/annurev-physiol-061121-040014. Epub 2021 Nov 1. PMID: 34724436; PMCID: PMC10228557. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10228557/
3. ASM.org. (2022, February 22). Evidence grows for vaping’s role in Gum Disease. https://asm.org/press-releases/2022/feb-2022/evidence-grows-for-vaping-s-role-in-gum-disease
4. Wold, L. E., Tarran, R., Crotty Alexander, L. E., Hamburg, N. M., Kheradmand, F., St Helen, G., Wu, J. C., & American Heart Association Council on Basic Cardiovascular Sciences; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; and Stroke Council (2022). Cardiopulmonary Consequences of Vaping in Adolescents: A Scientific Statement From the American Heart Association. Circulation research, 131(3), e70–e82. https://doi.org/10.1161/RES.0000000000000544
5. People who vape had worrisome changes in Cardiovascular Function, even as young adults. American Heart Association. (2022, October 31). https://newsroom.heart.org/news/people-who-vape-had-worrisome-changes-in-cardiovascular-function-even-as-young-adults
6. Kim, S. A., Smith, S., Beauchamp, C., Song, Y., Chiang, M., Giuseppetti, A., Frukhtbeyn, S., Shaffer, I., Wilhide, J., Routkevitch, D., Ondov, J. M., & Kim, J. J. (2018). Cariogenic potential of sweet flavors in electronic-cigarette liquids. PloS one, 13(9), e0203717. https://doi.org/10.1371/journal.pone.0203717
7. Goel, R., Durand, E., Trushin, N., Prokopczyk, B., Foulds, J., Elias, R. J., & Richie, J. P., Jr (2015). Highly reactive free radicals in electronic cigarette aerosols. Chemical research in toxicology, 28(9), 1675–1677. https://doi.org/10.1021/acs.chemrestox.5b00220
8. Goriounova, N. A., & Mansvelder, H. D. (2012). Short- and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function. Cold Spring Harbor perspectives in medicine, 2(12), a012120. https://doi.org/10.1101/cshperspect.a012120
9. Debnath, M., Debnath, D., Singh, P., Wert, Y., & Nookala, V. (2022). Effect of Electronic Cigarettes on the Gastrointestinal System. Cureus, 14(7), e27210. https://doi.org/10.7759/cureus.27210
10. Kankanamage, R. N. T., Ghosh, A. B., Jiang, D., Gkika, K., Keyes, T., Achola, L. A., Suib, S., & Rusling, J. F. (2020). Metabolites of Tobacco- and E-Cigarette-Related Nitrosamines Can Drive Cu2+-Mediated DNA Oxidation. Chemical research in toxicology, 33(8), 2072–2086. https://doi.org/10.1021/acs.chemrestox.0c00027
11. Australian Government Department of Health and Aged Care. (2023, December 20). About vaping and e-cigarettes. https://www.health.gov.au/topics/smoking-vaping-and-tobacco/about-vaping
12. Ma, S., Qiu, Z., Yang, Q., Bridges, J. F. P., Chen, J., & Shang, C. (2022). Expanding the E-Liquid Flavor Wheel: Classification of Emerging E-Liquid Flavors in Online Vape Shops. International journal of environmental research and public health, 19(21), 13953. https://doi.org/10.3390/ijerph192113953
13. Poklis, J. L., Wolf, C. E., 2nd, & Peace, M. R. (2017). Ethanol concentration in 56 refillable electronic cigarettes liquid formulations determined by headspace gas chromatography with flame ionization detector (HS-GC-FID). Drug testing and analysis, 9(10), 1637–1640. https://doi.org/10.1002/dta.2193
14. Eaton , D., Kwan, L., & Stratton, K. (Eds.). (2018, January 23). Nicotine – public health consequences of e-cigarettes – NCBI bookshelf. National Library of Medicine – NCBI. https://www.ncbi.nlm.nih.gov/books/NBK507191/
15. Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., & Bhadoria, A. S. (2015). Childhood obesity: causes and consequences. Journal of family medicine and primary care, 4(2), 187–192. https://doi.org/10.4103/2249-4863.154628
16. Welsh, E. T. (2021, October 1). E-cigarettes with nicotine may affect thrombotic activity, impair microcirculation. Healio. https://www.healio.com/news/pulmonology/20211001/ecigarettes-with-nicotine-may-affect-thrombotic-activity-impair-microcirculation
17. European Respiratory Society. (2021, September 6). E-cigarettes containing nicotine cause blood clotting and make small blood vessels less adaptable. ERS. https://www.ersnet.org/news-and-features/news/e-cigarettes-nicotine-blood-clotting-blood-vessels/
18. Glantz, S. A. (2017, March 11). E-cigarettes clobber platelets as much as cigarettes. Center for Tobacco Control Research and Education. https://tobacco.ucsf.edu/e-cigarettes-clobber-platelets-much-cigarettes
19. Hom, S., Chen, L., Wang, T., Ghebrehiwet, B., Yin, W., & Rubenstein, D. A. (2016). Platelet activation, adhesion, inflammation, and aggregation potential are altered in the presence of electronic cigarette extracts of variable nicotine concentrations. Platelets, 27(7), 694–702. https://doi.org/10.3109/09537104.2016.1158403