When they first arrived on the market, e-cigarettes seemed like the savior for nicotine disciples, a way to get that stimulating buzz without the risk of illness and death associated with tobacco. Now, as a few have predicted, more and more research is showing these digital vapor delivery systems aren’t as safe as we thought.
Two recent papers on e-cigarettes shed light on carcinogenic chemicals released in the vaporizing process, including noxious ingredients in certain flavor additives and heavy metals such as lead leached from the heating coils.
A third study published in PLOS ONE and released today by a team of researchers from the Norris Cotton Cancer Center at Dartmouth College suggests that, overall, e-cigarettes do more harm than good. While e-cigs may help some smokers quit, they seem to do a better job of encouraging never-smokers to pick up the habit. Specifically, the researchers estimated that smoking e-cigs in 2014 led about 2,070 current smokers to quit the following year, but that 168,000 people ages 12 to 29 who'd never smoked before would start smoking cigarettes and become daily users between the ages of 35 and 39.
The researchers estimate that e-cigarette use in 2014 would lead to 1.5 million years of life lost across the entire US population. Perhaps most troubling, these devices are especially attractive to teens and young people.
Exactly how vaporizers can lead kids to start smoking cigarettes is complicated. Obviously, addiction to nicotine is a big factor, according to Samir Soneji, the study’s principal investigator and an associate professor at The Dartmouth Institute for Health Policy and Clinical Practice. But not all e-cig juice contains nicotine.
“[Teens are] also introduced to the behavioral cues of smoking,” Soneji tells Tonic. “There's no flame in e-cigarettes, but there's a light, and you bring this cigarette-like object to your mouth, you inhale, you exhale a plume of vapor or smoke, so it's a very similar kind of behavior” he says, adding “studies have found that kids who hang out with other vapers change their attitudes around smoking…They start to have lower perceptions of harm around smoking, their attitudes change.”
A recent analysis of more than 800 peer-reviewed studies supports the conclusion that e-cig use in young people increases the risk of smoking regular cigarettes. But it’s still much easier for teens to get e-cigarettes than traditional cigs.
Until 2016, when the Food and Drug Administration introduced some nationwide vaporizer regulations, 10 states plus Washington, DC, had zero age restrictions—meaning 16 million kids could legally purchase e-cigs. Now you must be at least 18, and in some states 21, to purchase e-cigs. (One report from Weill Cornell Medicine warned that establishing the same purchasing age for e-cigarettes as for regular cigarettes would encourage teens to smoke the latter, because it assumed teens substitute vapes for “real” cigs.)
Yet according to Soneji and others I talked to, many teens are simply ordering vaporizers online. Most websites ask for an age, but it’s easy to lie. But there are other reasons teens use e-cigs—for one, vaporizer use is easier to hide.
“It's hard for kids to smoke during the day. We call them ‘opportunistic smokers,’” says Mark Rubinstein, a professor who studies adolescent medicine at University of California San Francisco. “A lot of them obviously can't smoke at school and it's hard to smoke at home because your parents can smell it. So theoretically because these products are easier to conceal, kids can use them more frequently than they would normally use a cigarette.” Even in school.
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While generally marketed as “safer” than combustible cigarettes, recent research from the American Academy of Pediatrics, which Rubinstein led, suggests they’re not safe. His team analyzed the urine of 83 adolescents who used either e-cigs alone (67) or e-cigs and regular cigarettes (16), and compared the samples to those from 20 non-smoking teens. They made sure the control participants were not exposed to secondhand smoke from tobacco or marijuana and also controlled for environmental exposure.
They found that vapers’ urine contained higher levels of “volatile organic compounds,” including acrylamide, acrylonitrile, and propylene oxide, some of which are carcinogenic at low doses. On average, levels of toxic organic compounds were up to three times higher in e-cig users than in non-smokers. In teens who use both kinds of cigarettes, levels were up to three times higher versus people who only vaped.
Among the teens who used only e-cigs, the use of fruit-flavored e-juice was associated with significantly higher levels of acrylonitrile. Some of the teens who vaped used e-juice that didn’t contain nicotine, but even their urine had elevated levels of three compounds compared to non-smokers. It’s the first known study to analyze the presence of potentially cancerous chemicals in the bodies of vaping teens.
“We don't really know what's in a lot of these products that are manufactured overseas,” Rubinstein tells Tonic. “It says six milligrams of nicotine, but is that true? There's no FDA regulation checking into that. Could there be other toxic substances, just like some of the toys that were manufactured overseas had lead in them? There's literally no oversight.” The chemicals are not listed in the liquid’s ingredients; they fall under “flavorings.”
In June, the FDA announced that it would delay regulations on how e-cigs are marketed by four years and that it planned to limit the amount of nicotine in traditional cigarettes. It’s worth noting that some tobacco companies like Marlboro owner the Altria Group and Newport owner Reynolds American make both traditional cigarettes and e-cigs, and some saw the move as an opportunity for tobacco companies to ramp up their e-cig business.
Back to the chemicals: Soneji uses benzaldehyde as an example. It’s naturally found in apples, apricots, and cherries, and is an almond-scented additive in many foods, such as cherry Jolly Ranchers—and cherry-flavored e-cigs. The FDA says it’s “generally recognized as safe,” a distinction that means a food additive is regarded as non-toxic by experts. However, some research shows that heating benzaldehyde can form benzene, a chemical long known to cause leukemia and other cancers.
When heating benzaldehyde at high temperatures, Soneji explains, “That chemical compound starts to break down and you get sometimes free radicals, you get other kinds of derivatives that you would never get by eating…There's a misperception that just because a flavor name is safe to eat, it's safe to breathe. And that’s just not true.”
E-cigarettes are often marketed as a form of harm reduction for smokers, as they’re generally considered safer than the cancer-causing alternative. But as Soneji found in his research, e-cigarettes aren’t that much more effective at helping smokers quit compared to nicotine replacement therapy, such as Nicorette gum or patches. At best, e-cigs are equally effective, but possibly less so, which is why he argues that the harms of e-cigs outweigh the benefits.
“They may be better than cold turkey, but of course cold turkey is not an effective way to quit,” Soneji says. “If they can make [e-cig] products really effective at helping smokers quit, on the order of twice as effective compared to nicotine replacement therapy, then we have a different conversation.”
Rubinstein agrees, but says e-cig marketing is often at odds with this aim. “I understand the complication—they want to make these products enticing enough to adults to get them to switch over as a form of harm reduction,” he says. “But the hardened adult smokers, the 70-year old man who has been smoking for 50 years, I don't think is going to pick up a bottle of rainbow unicorn poop.”
Rubinstein isn’t exaggerating—unicorn poop is a real e-juice flavor. And bizarre, sugary flavors—such as Red Bull, birthday cake and pumpkin pie—are more attractive to kids than adults, he argues. If kids start using e-cigs because of the flavors, then move on to regular cigarettes, that’s a problem.
“This is the same marketing playbook again with e-cigarettes as it was for cigarettes in the last century,” Soneji says, noting that e-cig advertising is not as regulated as marketing of combustible cigarettes. “You try to hook kids with appealing flavors, with appealing marketing.”
But some, such as Iowa Attorney General Tom Miller, have argued that this is an oversimplification, as there will “always be a [flavor] category that has higher youth uptake.”
Finding a balance between e-cigarettes as a smoking cessation tool or an adult recreational toy won’t be easy and will likely require more regulation from the FDA, of which, “there’s really none, other than age,” Rubinstein says. He went to far as to say in a release about his recent paper that “while they may be beneficial to adults as a form of harm reduction, kids should not be using them at all.”
Saying e-cigarettes are safer than cigarettes seems to be accurate, but to say they are completely safe—especially for young people—is just not supported by the current data.
“Some individuals may be able to use e-cigs to stop or control their tobacco addiction, on a population basis this is an extremely dangerous and foolhardy approach to take,” says Bruce Trigg, interim medical director for the Harm Reduction Coalition. “Big Tobacco is responsible for millions of deaths as a result of their pursuit of profit. Half of their customers die as a result of using their product, so figuring out ways of luring young people into this addiction is necessary for their survival.”
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