In 2003, Hon Lik, a 52-year old pharmacist, inventor, and smoker from Beijing, China, created a battery-powered device that converts a specialized aerosol liquid into an aerosol vapor for inhalation after the father of Hon Lik who smoked traditional cigarettes died from lung cancer. At the time, Lik worked at Golden Dragon Holdings, where the product developed and named as Ruyan, which means “like smoke.” The device was created based on the first smokeless tobacco device patented by Herbert A. Gilbert from the United States in 1963 in which the method involved replacing burning tobacco and paper with heated, moist, flavored air. It never commercialized at that time due to the popularity of traditional cigarettes and the uncertainty of companies to market the device. The device created by Hon Lik called e-cigarette was the first successful commercialized e-cigarette in the world that began in China (CAASA, n.d.).
Next, I will discuss the issue of e-cigarette in health safety. Since 2006 when e-cigarettes first introduced to the European and American markets until today, they are gaining more sales and popularity than traditional cigarettes in many different places in the world, especially in Europe and the U.S. as technology continues to improve the specifications of the device. Not only that, they are becoming alternative replacements for traditional cigarettes and used for health purposes such as nicotine replacement and smoking cessation therapy. However, the health sectors and scientists are still unclear about the health effects of e-cigarettes and questioning until today if e-cigarette is the solution to the worldwide health problem caused by combustible traditional cigarettes and a safe alternative to encourage adults to quit smoking. Alternatively, this can a potentially explosive device that addicts youth to nicotine and cause serious health problems.
Recently in the news media, the health sectors in the U.S. asked health care providers to be on alert for lung injuries related to e-cigarette among young adults after numerous hospitals reported several “severe” cases in August this year. As of November 20, 2019, about 2,290 cases of e-cigarette or vaping product use associated lung injury (EVALI) have reported to CDC from 49 states with 47 deaths. As for now, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) is still investigating the causes of lung disease. They cannot confirm that e-cigarette is the cause of lung disease outbreak. Aside from the outbreak, the Food and Drug Administration (FDA) warns consumers about the proper use of e-cigarette to avoid explosion and fire. Between 2009 until today, there were hundreds of documented incidents of explosion and fire involving electronic cigarettes reported to the U.S. Fire Administration (USFA). Countries like Turkey, Thailand, Cambodia, Norway, Singapore, Jordan, Panama, Brazil, and Argentina, according to Payne (2019), had declared already the total ban on the e-cigarette in terms of sales, importation, and possession. The World Health Organization (2008), on the other hand, does not eliminate the possibility that the e-cigarette could be used as a smoking cessation aid unless the scientists accepted a piece of universal evidence to proof that e-cigarette can apply for the smoking cessation therapy. Due to the recent lung injury outbreak in the U.S., the current U.S. President, Donald Trump, Malaysia, China, India, and President Rodrigo Duterte in the Philippines said in the news media that they would plan to ban e-cigarettes entirely for the safety of the consumers. Recently, the Department of Health (DOH) confirmed a 16-year-old girl from Central Visayas who used e-cigarettes for six months suffered from e-cigarette or vape product use associated lung injury (EVALI) on November 15 (Chavez, 2019). On the other side, the U.K. and most member countries of Europe except for Vatican City and Turkey are still supporting the sale and use of e-cigarettes but with the stricter regulations of the European Union (E.U.).
The issue of e-cigarettes is not new for the health sector. Now that e-cigarette, or vaping, product use associated lung injury (EVALI) incidents rise, some countries have no choice but to ban e-cigarettes or put stricter regulations for their safety. If this issue does not resolve, the cases of lung injuries with deaths will continue to increased overtime, and more money will be wasted just for health safety.
The U.K., the leading country that stands by the support for e-cigarettes as a cessation tool, believes that e-cigarettes help adults quit smoking and decrease deaths and disease caused by traditional cigarettes. A study by Gomajee, El-Khoury, and Goldberg (2019) conducted in France found that vapers were 67% more likely to quit smoking. According to the study of Hajek et al. (2019) from The New England Journal of Medicine, the e-cigarette is more twice as the rate of sustained 1-year abstinence was 18.0% in the e-cigarette group and 9.9% in the nicotine-replacement group. Long-term e-cigarette users had a higher quit attempt rate of more than 50% than short-term or non-users (Zhuang, Cummins, Sun, & Zhu, 2016).
A report by “The National Academies of Science, Engineering, and Medicine” (2016) stated that completely switching e-cigarettes for combustible traditional cigarettes conclusively reduces a person’s exposure to many toxicants and carcinogens and may result in reduced adverse health risks in several organ systems. Peter Hajek et al. (2019) also added that ongoing e-cigarette use might ameliorate withdrawal symptoms, such as constipation, mouth ulcers, and weight gain, and continue to provide some of the positive subjective effects previously derived from smoking. Plus, the long-term use of e-cigarette may also assist in preventing relapse among heavy smokers.
Since e-cigarette uses an aerosol liquid called e-liquid or e-juice, the e-cigarette can be a safer way to ingest a tobacco product than smoking a traditional cigarette that contains tar, which views for most of the carcinogens related with smoking. Public Health England (2015) stated that e-cigarettes are 95% less harmful to your health than regular cigarettes. Aside from nicotine, an e-liquid contains propylene glycol, vegetable glycerin, and flavorings. Propylene glycol is alcohol that used as an antifreeze ingredient for foods, cosmetics, and pharmaceuticals. Vegetable glycerin is also an alcohol and a natural substance that processed from vegetable oil. Propylene glycol and vegetable glycerin are non-toxic substances and safe for inhalation and swallowing since both of those substances are alcohols (Vaping Post, n.d.).
One of the primary sources of secondhand smoke from cigarettes is side-stream smoke that emits from the end of a lit cigarette and not inhaled by the smoker. Fortunately, the vapor is not emitted from e-cigarette when they are not in use. The levels of the toxicants in e-cigarette were 9–450 times lower than in cigarette smoke; thus, e-cigarettes may reduce exposure substantially to selected tobacco-specific toxicants (Goniewicz et al., 2013). Plus, the vapor from an e-cigarette is different from the smoke that comes from a traditional cigarette. According to McAuley, Hopke, Zhao, and Babaian (2012), traditional cigarettes produce side stream smoke continuously due to combustion, unlike e-cigarette. In other words, the total air emission concentrations (particle counts) resulting from vapor production for many pollutants were found to be very low, thus minimizing the risk limit for either children or adults.
E-cigarettes are safer for indoor use in terms of nicotine levels. Bush and Goniewicz (2015) found that the level of nicotine on surfaces in the homes of e-cigarette users compared was nearly 200 times lower. Thus, using e-cigarettes indoors results in much smaller (thirdhand) exposure to nicotine residues on surfaces compared to smoking tobacco cigarettes.
Not just only e-cigarettes help saving lives, improving the lives of everyone is also one of the roles of using e-cigarettes. According to Satel (2014), promoting electronic cigarettes to traditional cigarette smokers should be a public world health priority. Estimated to be more than $130 billion is the direct medical costs of smoking every year. Given that $150 billion annually in productivity losses caused by premature deaths, she added that there would be significant cost savings — as well as almost half a million lives saved each year if more smokers are getting to quit.
Norquist and Blair (2014) noted that e-cigarettes and vapor products are disruptive and innovative technology, creating thousands of good-paying jobs that are probably going to save hundreds of thousands of lives. The potential savings of e-cig adoption, and the resulting tobacco smoking cessation and harm reduction, could have been up to $48 billion in annual medical aid spending (Moody, 2015). This savings is 87% higher than all state cigarette tax collections and tobacco settlement collections ($24.4 billion) collected since 2014, according to Moody.
LaVito and Faber (2018) reported in CNBC that 1,500 employees of Juul, the biggest company in producing and selling e-cigarette, are receiving about $1.3 billion each due to partnership with other tobacco companies such as Altria. A letter signed by multiple organizations (2019) to U.S. President, Donald Trump warned that limiting the e-cigarette industry would cause lost tens of thousands of jobs for manufacturers of the devices and the stores that sell them. The vaping industry is simultaneously strengthening the working industry that drives the economy’s growth while reducing the need for governmental spending by creating more jobs (Spotz, 2018).
Despite e-cigarettes being better alternatives for traditional cigarettes, the new generation of youths is now engaging in vaping even at a young age that will cause nicotine addiction and introduced them to smoking. Cullens et al. (2018) noted that e-cigarette use among U.S. middle-high school students increased from 1.5% (220,000 students) in 2011 to 20.8% (3.05 million students) in 2018 and from 0.6% in 2011 (60,000 students) to 4.9% (570,000 students) in 2018 among U.S. middle school students. Berry et al. (2019) estimated that 21.8% of new ever cigarette use and 15.3% of current cigarette use in the U.S. youth population might be attributable to initiating tobacco products through e-cigarette use.
Many youths do not realize how they are harming their lungs and their brains by using e-cigarettes (American Lung Association, 2019). The amount of nicotine found in a cartridge of e-cigarette is about equal to the amount of nicotine in a pack of traditional cigarettes, or about 200 puffs, according to the website of JUUL cited by Truth Initiative (2018). Ross (2016) stated that nicotine is highly addictive in its own right, and it may lead to changes in brain activity that increase the risk of addiction to other drugs, especially in young people, and impair brain development in adolescents. He added that e-cigarette could lead to attention deficit disorder and poor impulse control. Truth Initiative added that flavors in tobacco products, including e-cigarettes, have been proven to appeal to youths resulting in likely to be misinformed about the harmfulness of the e-cigarettes. According to the survey conducted by Johnston, O’Malley, Miech, Bachman, and Schulenberg (2015), 66% of the respondents in grade schools claimed that the flavoring is the reason why they vaped.
The cases of e-cigarette, or vaping, product use associated with lung injury (EVALI) are continuing to increase right now with about 2,051 cases. The number proves that vaping can cause a severe health risk. Users of e-cigarette have a 71 percent higher risk of having a stroke, 59 percent higher risk of having angina or heart attack, and a 40 percent higher risk of having heart disease (Thompson, 2019).
E-cigarettes alter physiological hemostasis and increase the risk of thrombogenic events (blood clotting). Thus, their harm should not underestimate (Qasim et al., 2018). E-cigarettes are a possible source of exposure to toxic metals (chromium, nickel, zinc, manganese, and lead) when inhaled (manganese and zinc), potentially from the heating coils. Those metals from e-cigarettes are relating to health problems such as kidney diseases, respiratory irritation, shortness of breath, and more (Olmedo, 2018). Carbonyls like formaldehyde and acetaldehyde also come from the e-cigarettes after some ingredients used in e-cigarettes change composition when they heated by the heating coils (Geiss, Bainchi, & Barrero-Moreno, 2016). Those carbonyls are both carcinogenic and known to be harmful when inhaled at sufficient concentrations, even at relatively low wattages/temperatures.
E-cigarettes can also cause explosions while using it aside from diseases while using it that has led to the body parts loss (such as an eye, tongue, or tooth), third-degree burns, injuries in the roof of the mouth, and eventually, death. From 2015 to 2017, there were about 2035 e-cigarette explosion and burn injuries reported to U.S. hospital emergency departments (Rossheim, Livingston, Soule, Zeraye, & Thombs, 2018). According to Clark (2018), Rossheim’s study found that there is more than 40 times the number of injuries reported to the U.S. Food and Drug Administration (FDA) from 2009 to 2015. Also,15 times the total number of injuries reported to the U.S. The Fire Administration from 2009 to 2016, thus e-cigarette burn and explosion injuries are not rare, as was recently thought. Rossheim et al. (2018) said that users and bystanders risk severe bodily injury from unregulated e-cigarette batteries exploding.
American Airlines in Chicago, U.S. prohibit e-cigarettes in checked baggage due to the possibility of their lithium batteries catching fire after an American Airlines passenger’s e-cigarette battery overheated and ignited a small fire shortly after landing to Chicago in January 2019 (Ali, 2019). That same month, a 24-year-old Texas man named William Eric Brown died after an e-cigarette exploded in his face causing debris from the e-cigarette explosion to tore his carotid artery (Kesslen, 2019). Rosenberg (2018) also reported that a 38-year-old man in Florida named Tallmadge D’Elia died when his vape pen exploded, sending debris into his head and causing a small fire in his house on May 5. From January 2009 to December 31, 2016, there are 195 separate incidents of explosion and fire involving an electronic cigarette reported by the U.S. Fire Administration (McKenna Jr., 2017). The U.S. Fire Administration stated that no other consumer product that generally used so close to the human body has the lithium-ion battery that is the root cause of the incidents.
In the effort to minimize the number of e-cigarette injuries, different legislations and regulations are implementing across different parts of the world. In Europe, the revised Tobacco Products Directive by the European Union (E.U.) was implemented in full force on May 17, providing stricter regulations for e-cigarettes. The revised law limits e-cigarette advertising in print, on television, and radio, along with reducing the level of nicotine in liquids, reducing the flavors used, and the age limit of at least and not less than 18 years old to buy e-cigarette (action on smoking and health, 2017).
The Food and Drug Administration (FDA) is also banning minors (people whose ages are lower than 18 years old) from having access to e-cigarettes under its extended regulations as of 2016. A photo I.D. will be required to buy e-cigarettes. Their sale in all-ages vending machines in the U.S. is illegal. Through their extensive law, the Food and Drug Administration (FDA) will evaluate specific issues, including ingredients, product features, and health risks, as well as their appeal to minors and non-users.
As for the Philippines and most of the countries, they considered e-cigarettes as tobacco products; thus, vaping in public places is also prohibited just like smoking in their area. According to Administrative Order 2019-0007 signed by Health Secretary Francisco Duque III on June 14, the public smoking ban now covers e-cigarettes). Signed by President Duterte in 2017, E.O. 26, the Department of Health (DOH) prohibits smoking of cigarettes and other tobacco products, including e-cigarette in public areas such as schools and churches (Crisostomo, 2019). Republic Act No. 8749, named as Philippine Clean Air Act, is the support law for implementing the ban on e-cigarettes in public places to maintain the quality of air in public areas (Chavez, 2019). Lastly, the establishments engaged in the manufacture, distribution, importation, exportation, sale including online and transfer of e-cigarettes must get a license first from the Food and Drug Administration.
For now, e-cigarettes cannot be categorized as either beneficial or harmful unless the scientists and researchers come up with a common conclusion from the evidence. Those pieces of evidence by various scientists and researchers are still investigating and analyzing. All we need is to take precautions in using e-cigarettes, and most importantly, discipline on the physical health and lifestyle will be the key to achieve a more secure health safety.