How E-cigarettes Work

Electronic cigarettes simulate smoking. They are battery-operated devices used to inhale an aerosol, which usually includes nicotine, flavorings and other chemicals. E-cigarettes may look like tobacco cigarettes, cigars or pipes. Or they may resemble common objects like a large pen or a digital USB memory stick. The device holds a liquid solution that contains flavoring chemicals that are vaporized when puffing activates an electronic heating element.

Vapor Trails

E-cigarette aerosol is not harmless water vapor. The vapor may not contain tar like traditional cigarette smoke, but it still contains volatile organic compounds such as benzene that are carcinogenic. Youth who vape need to be warned about the health risks from exposure to cancer-causing compounds, the health dangers of nicotine, and the risk of future addiction to tobacco and other harmful substances.

According to the CDC, potentially harmful ingredients of e-cigarette vapor include:

• Nicotine
• Ultrafine particles that can be inhaled deep into the lungs
• Flavoring chemicals such as the solvents propylene glycol and glycerol, and diacetyl, a chemical linked to a serious lung disease
• Volatile organic compounds that are linked to cancer
• Heavy metals such as nickel, tin and lead

Secondhand Vapor

Secondhand vapor from e-cigarettes can harm those who are involuntarily exposed, including unborn babies and children, and can pollute indoor air. In addition, third-hand vapor clings to surfaces and dust, and can become a pollutant.

Taste Test

Adolescents may not know that e-cigarettes contain nicotine. They are drawn to e-cigs by the variety of appealing flavors such as mango, cheesecake, crème brulee, mint and blueberry. Manufacturers, who have marketed their products to youth, are not required to report the ingredients of e-cigarettes, so users don’t know exactly what’s in them. Nearly two-thirds of teens believe their e-cigarettes contain only flavoring. “I believe certain flavors are one of the principal drivers of the youth appeal of these products,” stated former FDA commissioner Scott Gottlieb (2018).

Negatives of Nicotine

The developing adolescent brain is particularly vulnerable to nicotine addiction.

(FDA, 2018)

Nicotine has unique consequences for adolescent brain development. During adolescence, brain circuits that regulate emotion and cognition—including decision-making and impulse control—are actively developing. Exposing a developing brain to nicotine can increase the risk for nicotine addiction; mood disorders like depression, learning and attention problems; and permanent impairment of impulse control.

“Even brief exposure to a low dose of nicotine can produce lasting change in the adolescent brain (Yuan, Cross, Loughlin, & Leslie, 2015).

In addition, “nicotine exposure, increasingly occurring as a result of e-cigarette use, may induce epigenetic changes that sensitize the brain to other drugs and prime it for future substance abuse” (Ibid.).

Long-Term Harm

“Some people have suggested that use of e-cigarettes by young people might ‘protect’ them from using cigarettes” (U.S. Surgeon General, 2018). “There is no evidence to support this claim. Some studies show that non-smoking youth who use e-cigarettes are more likely to try conventional cigarettes in the future than non-smoking youth who do not use e-cigarettes.” Safer doesn’t mean safe.

Youth who use e-cigarettes may be more likely to use:

• Combustible tobacco products (cigarettes, cigars and hookahs)
• Non-combustible tobacco products (smokeless tobacco/chewing tobacco)
• Alcohol
• Marijuana
• Other illicit substances
• Prescription drugs in ways that were not intended by the prescriber

All tobacco products contain nicotine. Cigarettes and other burned tobacco products cause most of the tobacco-related deaths and disease in the United States. Smokeless tobacco users have lower mortality risks than cigarette smokers, but smokeless tobacco also has been associated with serious and often fatal diseases (Fisher, Tan-Torres, Gaworski, Black, & Sarkar, 2019). “Tobacco use is the leading cause of preventable disease, disability, and death in the United States” (CDC, 2020).

Vaping and smoking cigarettes in adolescence or early adulthood can lead to lifelong addiction. “Age of first cigarette use is a critical determinant of tobacco dependence, with those who started in their early teens having the greatest difficulty quitting” (Yuan et al., 2015). “Thus, not only tobacco but also e-cigarettes must be considered as serious threats to adolescent mental health.”

Long-term health consequences of e-cigarette use include:

• Daily use of e-cigarettes is associated with a near doubling of the odds of a heart attack (University of California, San Francisco, 2018).
• Some sweet flavors in e-cigarette liquids such as pineapple and cotton candy may increase the risk of dental caries, according to research supported by the American Dental Association Foundation (Kim et al., 2018).

Alert: Vaping Linked to Severe Lung Disease

The CDC issued a health advisory on Aug. 30, 2019, after finding a multi-state outbreak of severe pulmonary disease to be associated with e-cigarette use. The CDC warned, “While this investigation is ongoing, if you are concerned about these specific health risks, consider refraining from using e-cigarette products.”

Hundreds of e-cigarettes users—many of them adolescents and young adults—have been sickened. Some require a ventilator to breathe. As of late February 2020, 68 individuals had died, and the investigation was ongoing.

The CDC warns that teens, young adults and women who are pregnant should not vape. “While the investigation continues, everyone else should consider not using e-cigarettes or other vaping devices” (Texas Health and Human Services Commission (HHSC) & Texas Department of State Health Services [DSHS], 2019).

Symptoms of patients with severe pulmonary disease due to e-cigarette use include:

• Cough, shortness of breath or chest pain
• Nausea, vomiting or diarrhea
• Fatigue, fever or weight loss

The CDC is calling on health-care providers to take action:

• Report cases of severe pulmonary disease of unclear origin (such as COVID-19) and a history of e-cigarette use within the past 90 days to state or local health departments.
• Ask all patients who report e-cigarette use within the last 90 days about signs and symptoms of pulmonary illness.
• If e-cigarette product use is suspected as a possible cause of a patient’s severe pulmonary disease, obtain a detailed history such as type of substance vaped, source of the substance and type of electronic device used.

In addition to refraining from vaping, the CDC is urging the public to:

• Refrain from modifying e-cigarette products or adding any substances to these products that are not intended by the manufacturer.
• Self-monitor for symptoms such as coughing, shortness of breath or chest pain if continuing to use e-cigarettes.
• Seek prompt medical attention if any health concerns arise.
• Call the local poison control center toll-free at 800-222-1222 with any concerns about harmful effects of e-cigarette products.

DSHS offers a vaping web page with a variety of resources and maintains a separate web page that includes updates about Texas and national cases of severe lung illness associated with vaping as well as the status of investigations. Link to both resources in the Appendix.