The Highs and Lows of Vaping: What Does Science Say?
Most people will recognize this as a vaporizer, an e-cigarette, or a vape mod. It is a delivery system for nicotine--or, increasingly, marijuana.
Vaping Popularity and Concerns
As people strive to stop smoking they look for alternatives and for techniques that help wean them off cigarettes. Vaping has become quite popular in this context. Also, as marijuana is legalized in more places in the world--just yesterday in Canada--vaping is becoming an acceptable alternative for marijuana consumption. While vaping is popular, there are skeptics, especially those who voice concerns about chemicals added to the vaping cartridge. Are these concerns legitimate? Are they important? Maybe....
Who Vapes?
How many people in the world vape (tobacco)? There's no way to tell. Millions who vape are not permitted to do so by law. This includes those who live in countries where vaping is banned, and also consumers who are underage. However, if we're looking for estimated usage, Vaping Daily offers a few statistics.
**10% of U. S. adults (in 2015, as per Reuters)
**11.6% of adults in the EU (in 2014, as per the British Medical Journal)
**The statistical picture for vaping usage gets even more nebulous in Asia, where legal status is variable. Vaping is allowed in China. More than 90% of electronic cigarettes are produced in China. One industry consultant is quoted as saying: "it remains difficult to gauge just how big an impact e-cigarettes are having on the Asian market."1 This is especially true in some countries where it is banned, but where there is demand.
A prison in Ratchaburi Province, Thailand, where you could end up if you try to vape in that country. It is reported that a ten-year sentence awaits violators. The picture is credited to the Thai government and is used under a Creative Commons Attribution-Share Alike 2.0 Generic license.
In Australia, it is estimated there are 240,000 "alternative device users", despite an outright ban.2
Vaping Marijuana : I don't think a valid survey of marijuana users can be taken, given the legal and social issues surrounding marijuana consumption. I won't spend too much time on this. However, there was a survey published in Drug Alcohol Dependence: Online Survey Characterizing Vaporizer Use among Cannabis Users and I'll include the results here for reader interest. According to this report, 61% of those reporting had vaped at some time in their lives, 12% considered vaping their preferred method of marijuana consumption.
Will any of the people who vape be influenced by a recent report that shows vaping is actually more harmful (to health) than smoking? In August of 2018, Dr. Constantinos Glynos, of the University of Athens, released the results of a study on tobacco vaping. The study subjects were mice, not humans. Nonetheless, the results weren't encouraging for the vaping industry, or for people who like to vape.
In his report, Dr. Glynos describes the inflammatory effect that vaping has on lung tissue. One goal of his study was to isolate exactly what it was about vaping that caused inflammation. An agent identified and implicated was propylene glycol (PG). The study demonstrated that the inflammatory effect of vaping with PG was actually greater than the effect of smoking cigarettes alone.
Damage to Lung Tissue Caused by Chronic Inflammation
This is an illustration of the harm long-term inflammation can do to the lungs. The inflammation can lead to (among other things) COPD (chronic obstructive pulmonary disease). In COPD alveoli in the lungs (pink sacks represented in the top cross section) are damaged. Gas exchange (oxygen for carbon dioxide, carbon dioxide for oxygen) takes place in the alveoli. When the alveoli do not work properly, people are constantly short of breath. COPD effects the overall metabolic rate of the individual. This metabolic change has a cascading influence in other parts of the body.
It is estimated that about 75% of all COPD cases are to due to smoking.
Specific clinical findings in the Athens study that were attributed to the presence of PG: increased cellularity in bronchoalveolar lavage fluid (BALF); increased production of Muc5ac; and the presence of oxidative stress markers. All of these are indications of inflammation. As explained in the Journal of Proteome Research: "Oxidative stress plays an important role in the development of airway inflammation..."3
These side-by-side images contrast normal lung and damaged lung tissue. The tissue on the left, from an asthma patient, shows acutely inflamed bronchioles. Bronchioles are tiny passages in the lungs that lead to the alveoli.
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In Defense of Vaping and Propylene Glycol
Though the study described by Dr. Glynos implicates propylene glycol in lung inflammation, the chemical has its supporters. It has been approved by various agencies around the world for consumer use. Also, numerous highly respectable sources have endorsed vaping as a healthy alternative to smoking.
For example, in 2016 Stanton Glantz, a professor of medicine and the Director of the Center for Tobacco Control Research and Education at the University of California, stated, "There is no question that a puff on an e-cigarette is less dangerous than a puff on a conventional cigarette". 4
Vaping is also seen by many as a smoking cessation aid. A 2018 study sponsored by the Cancer Research Center of the UK concluded that, for those who want to stop smoking, vaping may help. However, this judgment is challenged by other respected experts in the field. For example, Kenneth Johnson, Adjunct Professor at the University of Ottawa, views vaping as not only ineffective in smoking cessation but also as a gateway to smoking for the young.
What Are We to Make of It All?
As I finished reading these studies I was left with many questions. I looked further and discovered some interesting facts. I'll describe a few of them here:
I learned that PG can be found just about anywhere--in medicines, foods, vaporizers--and theatrical fog. I looked at each of these uses separately:
Medicine
In medicine, PG has been blamed for near-fatal events. This is especially true with the use of intravenous benzodiazepines. PG is the medium in which the drug is placed. A 2005 article in the medical journal, Chest, reported that PG toxicity was both "common and preventable". 5 What's fascinating about this is, there are other mediums that can be used (midazolam, for example), and these do not have the same potential for fatal overdose.
Food
Whisky pulled from the market in Europe. The picture credit is Pixabay (adapted--the writing on the barrels is mine 😎).
While PG is permitted as a food additive, regulations vary in the U.S., Europe and Canada. The U.S. allows up to a 5% concentration. In Canada, the statutory standard is "good manufacturing practices."6 In Europe, a 0.1% concentration is allowed. This last fact led to a curious incident in which a shipment of cinnamon whisky had to be pulled off the market in Europe. It contained PG at allowable U.S. standards. The shipment had been mislabeled and sent to the wrong continent, where it was illegal.
Theatrical Fog
The picture shows a portable fog/smoke machine, hooked up to a fan for dispersal of the fog/smoke. This is the sort of device that may be used to create a mood in theatrical productions. The venue in which the device might be used can also include a school, or the home (for a private party). What most people who rent these devices don't realize is that the artificial fog/smoke generated has been implicated in the development of respiratory ailments. The photo above is credited to Jocelyn Morel and is free of copyright restriction.
It turns out, PG is a component of theatrical smoke/fog. Because of this, health experts have been able to gauge the health impact of long-term exposure to PG in the fog. Their findings reveal that people most exposed (longer periods, nearer the source) suffer the greatest incidence of respiratory events. Another component of the fog that was determined to be a respiratory irritant was mineral oil. This actually seemed to be a bigger problem than the PG.
Properties: Liquid, Odorless, Colorless, Water Soluble
Molecular Formula: C3H8O2
I'm Afraid There's Another Health Concern with Vaping
Formaldehyde
If you're vaping tobacco, then propylene glycol is likely mixed with tobacco (along with other ingredients) in your cartridge. If you're vaping marijuana (medicinal or otherwise), there's a good chance propylene glycol and polyethylene glycol (PEG) are used. Both chemicals release formaldehyde when heated. In tobacco vaping, the amount of formaldehyde exposure may be affected by the way you smoke.
Tobacco vaping can be done at a high voltage or a low voltage. A report issued by the New England Journal of Medicine states that if tobacco is vaped at a high voltage, "more than 2% of the total solvent molecules have converted to formaldehyde-releasing agents, reaching concentrations higher than concentrations of nicotine." The report, Hidden Formaldehyde in E-CigaretteAerosols goes on to explain that the International Agency for Research on Cancer has declared formaldehyde to be a group 1 carcinogen. 7
In marijuana vapes, according to the Journal of Alternative Complementary Medicine, high temperatures necessary for vaping (230°C) result in formaldehyde release for both PEG and PG. However, PEG "produced significantly higher levels of acetaldehyde and formaldehyde than PG ".8 It seems that breathing acetaldehyde, even for short periods,"can hurt your lungs". That's according to the Delaware Department of Health.9
A Second Look
I think it's pretty safe to say that questions about vaping will not be resolved by this brief blog. Responses I have received to the blog indicate that people pretty much seem to start the blog and end it with their inclinations intact. This makes sense, because the research conducted is suggestive and fairly recent. One comment by @mathowl sent me looking this morning for clarification about exposure to formaldehyde through vaping. Are there filters that can protect the smoker? I'll simply cite the (fairly recent) research that addresses this question:
A report issued by researchers from Johns Hopkins in December of 2018 indicated that nicotine, as delivered by e-cigarettes and in the absence of tobacco, proved to be carcinogenic in mice. This effect was seen not only in lung tissue but also in bladder and heart tissue. The researchers found: "...mutagenic O6-methyldeoxyguanosines and γ-hydroxy-1,N2-propano-deoxyguanosines in the lung, bladder, and heart" 10. Also, they found that the native ability for damaged tissue to repair itself was reduced.
An article published by researchers from Portland State University indicates that the formaldehyde delivery may actually be more noxious in e-cigarettes than previously discovered. These researchers report: "formaldehyde hemiacetals, a new form of formaldehyde, may...deposit more deeply in the lungs compared to gaseous formaldehyde". 11
And then there's the article in Rolling Stone (October 2017) that lists a series of hazards that may exist in marijuana vapes. These include granulomas that may form in the lungs from concentrated wax extracts (found on the outside of a cannabis leaf). There is also a discussion about formaldehyde, which is an issue I address in the earlier part of this blog.
Finally, I came across an article about the air quality at a vaping convention. Not good.
I didn't find any mention of formaldehyde filters that might protect people who vape from some of the cited hazards--although I did look for this information. If anyone else finds legitimate research sources that show these filters are effective, please share those sources with me, and other readers.
The discussion continues....
Footnotes:
1 Jackie Zhuang, in Vaping Statistics: How Many Vapers Are There? Vaping Daily
2 https://asia.nikkei.com/Politics/Asian-consumers-push-for-right-to-use-smoking-alternatives
4 https://www.livescience.com/54754-what-e-cigarettes-do-in-your-body.html
5 Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series and prospective, observational pilot study
7 New England Journal of Medicine Hidden Formaldehyde in e-Cigarette Aerosols
9 https://www.dhss.delaware.gov/dph/files/acetaldehydefaq.pdf
Some Resources Used in Writing This Blog
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
https://www.lonelyplanet.com/news/2018/07/12/countries-where-vaping-is-illegal/
https://vapingdaily.com/blog/vaping-statistics/#vapingStatistics2
https://vapingdaily.com/blog/vaping-statistics/
https://tobaccocontrol.bmj.com/content/26/1/98
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4745650/
https://www.atsjournals.org/doi/full/10.1513/pats.200504-026SR
https://copd.net/basics/causes-risk-factors/smoking/
https://medical-dictionary.thefreedictionary.com/Bronchoalveolar+lavage+fluid
https://medical-dictionary.thefreedictionary.com/MUC5AC
https://www.ncbi.nlm.nih.gov/pubmed/19714806
https://medicalxpress.com/news/2018-04-doctors-e-cigarettes-smokers.html
https://www.chemistryworld.com/podcasts/propylene-glycol/3007464.article
https://www.researchgate.net/publication/271389456_Hidden_Formaldehyde_in_E-Cigarette_Aerosols
https://www.ncbi.nlm.nih.gov/pubmed/28355118
https://asia.nikkei.com/Politics/Asian-consumers-push-for-right-to-use-smoking-alternatives
https://www.ncbi.nlm.nih.gov/pubmed/19714806
https://www.livescience.com/54754-what-e-cigarettes-do-in-your-body.html
https://www.ncbi.nlm.nih.gov/pubmed/16162774
http://www.hc-sc.gc.ca/fn-an/securit/addit/list/archive-8-other-autre-2017-05-02-eng.php
https://www.nejm.org/doi/10.1056/NEJMc1413069
https://www.ncbi.nlm.nih.gov/pubmed/28355118
https://pubchem.ncbi.nlm.nih.gov/compound/1_2-propanediol#section=2D-Structure
Hey, how spectacularly useful of you, I was planning on a running a seminar activity on vaping this coming week. My general plan was something along the lines of “Should a healthcare system incentivise the use of e-cigarettes?”.
The links you have here are a great start, thank you!
Some thoughts:
• I honestly don’t yet have an opinion either way on this just yet (something that’s very rare!).
• I had no idea that some countries had banned their use (although it makes sense now that I think about it). I wonder how much of that is down to pushing from big tobacco.
• If used as an aid to quitting rather than a replacement the (possible) greater negative effects might be outweighed by the long term gains from successful cessation.
• That long-term effects by using data from theatrical smoke is a great example of a scientist thinking outside the box! I’m blown away by the ingeniousness.
Sadly, it’s of course far more complicated than this. If incentivised more people will do it, if there are disincentives less will do it. This then becomes a public health issue, it’s too much to expect members of the public to assess all of the scientific literature and weigh up the pros and cons without bias. How the system reacts will make all the difference.
So much to think about here. Thanks!
:) Never underestimate the public. People spread knowledge through scientific findings wide and far. I haven't known the harming facts in detail but it's already common sense here in Germany that the e-cigarette smoke is damaging. If people nevertheless decide in doing unhealthy things it is them who must deal with the consequences.
I guess it happens to you too, that if you are, for example, dealing with health topics within your social circle, your sibling or parent might not openly agree with you but your words do have some weight and secretly your people (or friends or whatever) took to their hearts what you've told them? And vice versa?
For the rest, which is not being taken up by another person, one can let go of trying to convince or teach a person, no?
Curious you say that, about having an effect on family. A few years back my brother was stricken with a mysterious illness. It defied diagnosis and he was deteriorating fast. We (nieces, nephews, wife and I) put our heads together and helped to guide the diagnosis. It turned out to be a rare disease--though we're learning it is not so rare, but rarely recognized.
And yes, I learn to keep my opinions to myself more as I grow older. After all, I am so often wrong :)
What a great reply. I had originally added a line at the end which suggested we could make up our own minds or allow a regulatory agency to do that for us. My husband didn't like the sound of it, so I cut it out:) I have mixed feelings--I think you're right that industry sways regulation. It's one of the reasons people are suspicious of government action (we're back to your blog on trust!). So many discrete influences the public never learns about. Incentivizing, rather than regulating, is likely to be more effective. Education and information. Otherwise, black markets will always spring up. People find a way to do what they want.
I'm glad you find the references useful. When I write a blog like this I learn so much. Hard to keep it compact, but I feel for the reader so this awareness tempers my inclination to say more.
Yeah, all of this health recommendation business it’s a hard balancing act. The Nuffield ladder of intervention is often a good framework to when thinking about public health policy. Each step up is philosophically different from the step before. If an intervention is important to health there is often more we can do that just provide information and let people decide for themselves, but equally head too far up the ladder and we run the risk of committing some pretty intense ethical violations.
I love the ladder--"doing nothing is an active policy decision". It's actually comforting to see that policy-making is systematized logically and rationally. Fascinating reflection of values. I can see how these might vary depending on culture and education. Quite a field you've chosen--constantly evolving. You'll be learning and studying the rest of your life :)
I like to vape my cannabis. I do not mix it in a vape solution(vegetable glycerin and glycy propal) though. Just vape it alone in my Arizer.
Seems, from what I read, you are wise to avoid the additives. Glad you know what you're doing :)
My suspicious and cautious mind about the many alternatives, be it pills instead of real fruit and vegetables or muscle-building supplements instead of accepting the ability to build muscles, were also concerned about smoking substitutes: I feared that they would make it worse.
Thank you for the confirmation.
In the vernacular this knowledge already arrived here and at all we seem to be here in Germany quite picky with the maximum amounts - I hope, this remains also further in such a way under the protection rule of the European Union.
I like it, that a ship was sent back. This was the best part of reading your article as it shows that the laws do function and are not just a public relations move.
I have very often smelled this sugary fog. As a young woman I went regularly with friends to the disco and there this vapor was sprayed very regularly and several times in one night. It smelled very sweet and at that time I had a queasy feeling to breathe it in, but was not sensible enough to leave the dance floor for so long.
Your research is really hellish! :) See me bowing in front of your patience and accurateness in finding different sources.
You are kind, friend. It is a peculiarity of my personality that I love to do research, and there are always questions that come to mind. Steemit is one of the rare places where odd questions can find an audience. It seems that if a blog is responsible and not tedious, there's usually someone who is interested. This is a great experience for someone like me.
As for the smoke/fog--my daughter has performed professionally (as a dancer). She said she always found the smoke/fog irritating. She felt validated when I told her what I learned.
Regulations in the EU seem to be more stringent than in the U. S., in many areas. I couldn't believe Canada has no objective standard, at all.
I am in love with odd questions. Questioning in itself is an art & I cannot remind myself enough in doing that. Forget it often enough and fall into the pattern of "telling". Though I hesitate to ask too much and steal people their time.
That is so interesting that your daughter is a dancer. I have no friends or family members who are on stage performing. I try to imagine to sit in the audience as a mother. Must feel good.
... Oh, wait! I forgot a friend who is an amateur actor in a boat theatre on the outskirts of Hamburg. He's really good and has been playing in the ensemble for over ten years.
The nice thing about writing, for me--it invites self control. Speech can be more voluminous. Writing often allows for edits and reconsideration.
Yes, my daughter does make me proud. I am glad she found a way to express herself and earn money through art. It's amazing to me that she became a performer, because I am such a private person. Though my daughter reminded me once that I used to dance at home spontaneously in response to music. I'm glad she has that memory.
I kinda liked the smell of this smoke. But maybe it was the association with the environs and alcohol etc.! Even thinking about it now brings all those other images tagging along, of music and dancing etc.
My daughter performed in some high-end productions. Maybe they used a different kind of smog/fog. She sure wasn't drinking--not while she was dancing. Would have been dangerous. I think you may have had a different experience :)
Excellent piece.
IMHO, it appears to be a lesser evil than cigarettes.
Namaste, JaiChai
I'm withholding judgment. It's hard to say I favor cigarettes when both vaping and cigarette smoking cause such harm. But I think vaping is a false promise. Thanks for your feedback, JaiChai :) Always appreciated.
I know there exist formaldehyde filters. Maybe it is possible to filter it from the smoke without actually removing everything.
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Thanks for that suggestion.
So I spent some time this morning looking up research about formaldehyde filters and did not find anything that suggested their utility for vaping. However, I did come across a few more articles--more specific research--about how vaping affects people. I added that to the bottom of my blog, and referenced your question there.
Frankly, after all the reading I've done, I don't think people should be surprised that chemicals delivered directly to lung tissue might not be a good idea :)
This post was shared in the Curation Collective Discord community for curators, and upvoted and resteemed by the @c-squared community account after manual review.
Thank you for your support!
Is smoking legal in those countries where vaping is illegal? I just don't get the rationale. Could they possibly be so up to date with Glynos' work?
I don't think a decision like that is ever free of monetary or political influence.
I had no idea this was banned in so many countries; I wonder if big tobacco companies have anything to do with that. My son quit smoking cigarettes and switched to e-cigs; I always wanted him to drop both and figure out why he's still so attached to the nipple haha (I only got an exacerbated mom from him as a response :)
We're beginning to see studies from short-ish/long term studies from e-cigs, and I'll be curious what the future holds. STands to reason that they're not good for you, at least for me anyway :)
Thanks as always for a thought-provoking post @agmoore. Submitting to c-squared too.
Thanks, @lynncoyle1 Tell him to stop. Forward my blog. Lots of references there. Of course he won't listen to Mom but he might listen to others. We never listen to Mom or Dad --until we're old enough to look like them :)