For some time now, everything has gone electronic! Even cigarettes! Hence the term e-cigarette. In this article, I hope to convey the basic differences between the traditional (conventional) cigarette with which we are all very familiar and the e-cigarette. The e-cigarette was first developed in 2003 by a Chinese pharmacist, Hon Lik. And after China, it made its appearance in the United States (US) and the United Kingdom a few years later. The US and the European Union (EU) appear to be the only countries where e-cigarettes are on retail sale legally.

The ill-effects of cigarette smoking are well-known now and need not be repeated here. However, the ill-effects of the e-cigarette through what is now known as vaping, as reported, will be emphasised. Australia, Canada, Israel, Mexico and some cities (Los Angeles, Chicago, New York) have banned e-cigarettes or restricted their use in some public venues, “vaping lounges” or stores where they are sold.

As opposed to the traditional cigarette which is smoked by burning tobacco leaves, the e-cigarette, being tobacco-free, involves vaping only. Electronic cigarettes are actually vaporisers with a mechanism that heats up a liquid to a temperature of roughly 100-250 °C turning it into an aerosolized vapour which is inhaled or “vaped”. With e-cigarettes, there is nothing to light. In- stead, they run on rechargeable lithium-ion batteries. They contain a vaporization chamber or a cartridge filled with liquid. The liquid in a cartridge can be resupplied regularly by inserting a new cartridge or refilling an empty one.

When you puff on your e-cigarette as you would with a regular cigarette, the battery powers the device to heat the liquid and vaporizes it. Since it does not burn tobacco, there is no smoke, no carbon monoxide, no tar and no odour. And you could also extrapolate to say not the majority of the 7,000 (noxious) chemical substances emanating from cigarette smoke often referred to and of which 69 are known carcinogens. Yes! And the levels of a few toxicants (Formaldehyde, Acetaldehyde, Acrolein, Toluene, Nitroso-nornicotine and one other complex chemical – 4-(methyl nitrosamino-1-(3 – pyridyl)- 1-butanone) – common to both (when measured in micrograms) have been found to be far less in an e-cigarette than in a conventional cigarette.

But I hurry to add that the e-cigarette is not NICOTINE FREE! The liquid in e-cigarette is typically a combination of nicotine, flavouring, propylene glycol or vegetable glycerine (from plant oils, e.g. palm oil) and may be, with other additives. The amount of nicotine depends on the mixture of the particular liquid nicotine cartridge installed in the electronic device. Some products contain nicotine in amounts comparable to regular cigarettes whilst others closer to that of a so-called light or ultra-light cigarette.

Everyone, including cigarette manufacturers, agrees that cigarette smoking can be bad for one’s health. Our cardiologists continuously advise about the dangers of smoking. As vaping is fairly recent, there are ongoing debates concerning its effects on health and I have gathered arguments from various quarters and, of course, you could add your own additionally to make the discussion interesting. Let us first review the main constituents of the liquid (also referred to as e-liquid) used in e-cigarettes and their negative effects on health.

Nicotine

Nicotine, the common ingredient, in e-liquids and from tobacco, is a highly addictive substance. It is this addiction, anyway, that makes it difficult for smokers to quit the habit. Nicotine is extracted from the tobacco plant Nicotiana tabaccum, named after the French ambassador to Portugal Jean Nicot de Villemain who sent tobacco seeds to Paris in 1560 and was presented to the French king who promoted their medicinal use. It was thought to protect against plague. It is interesting to dig out the historical origin of some words!

Nicotine has been one of the earliest known insecticides since the 18th century but is now no longer used. Smokers and vapers should realise that they are introducing a POISON in their bodies. The pharmacology, neuropharmacology and toxicolology of Nicotine are now well documented. Nico- tine is said to be more addictive than heroin or cocaine. Hence doctors’ orders for not smoking and advising to quit. Though ironically many doctors are themselves addicted to this habit!

“With the advent of e-cigarettes, ‘NO VAPING’ will inevitably have to be added in the not too distant future to the already well-acquainted ‘NO SMOKING’ sign.”

Flavours

You will be surprised to learn that one count a couple of years ago came up with about 3,700 flavours available (Think of all the flavours you choose when buying ice-cream: vanilla, chocolate, strawberry, mint, almond and many more). Although many of the flavours are food additives and perhaps proven safe when ingested, it does not follow that they are safe when inhaled all the time. For example, the compound, diacetyl, coming from butter flavour, the same that is found in popcorn, has been found to be present in 75% of e-cigarettes tested. This butter flavour of popcorn is apparently safe when consumed.

However, inhalation of diacetyl has caused a severe respiratory disease known as bronchiolitis obliterans (“popcorn lung”) in workers producing the snack. It is questionable whether the amounts inhaled from e-cigarettes could also cause such a condition? The same remark would apply to other harmful chemicals that might be present from other flavours in e-cigarettes. In this regard, it is to be noted that inhalation toxicity studies are very expensive and may take several years. Furthermore, results of trials with rats cannot be directly extrapolated to humans. Professor Thomas Hartung, responsible for evidence-based toxicology at Johns Hopkins Bloomberg School of Public Health, in the US, recommends in the short term (self) restricting the use of additives and using computer-based evaluations to help clarify the use of e-cigarettes. In the medium term, anyway, controlled trials will be necessary.

A report from surgeon general

It is pertinent to consider below some observations and conclusions found in a very recent report of the Surgeon General, US Public Health Service, on e-cigarette use among youth and young adults. E-cigarettes are now the most commonly used tobacco product among youth, surpassing conventional cigarettes in 2014. E-cigarette use is strongly associated with the use of cigarettes and other burned tobacco products. E-cigarette use among youth and young adults has become a public health concern.

In 2014, current use of e-cigarettes by young adults (18-24 years of age) surpassed that of adults 25 years of age and older. Many e-cigarettes contain nicotine which is highly addictive and also unsafe for the youth. The ingestion of e-cigarette liquids containing nicotine can cause acute toxicity and possible death, if the contents of refill cartridges or bottles containing nicotine are consumed. Actual cases have been reported. Other constituents of e-cigarettes, such as solvents (e.g. propylene glycol), flavours and heavy metal particles (e.g. nickel, tin, lead) from the aerosol created by e-cigarettes can be harmful.

Finally, the report suggests that parents, teachers, healthcare providers and others who influence youth and young adults can advise and inform them of the dangers of nicotine and discourage them of the use of tobacco in any form, including e-cigarettes. They should also set the good example by being tobacco free themselves.

Legislation

The Food and Drug Administration (FDA) in the US, since 2014, regulates the manufacturing, importing, packaging, labelling, advertising, promotion, sale and distribution of e-cigarettes. A similar legislation prevails in the EU countries.

Secondhand exposure

Second-hand exposure (i.e.one being exposed to the smoke of a nearby cigarette smoker and very often when one is a non-smoker and again now being exposed to the volatile chemical products emanating from the e-cigarette of a vaper) has always been considered a real health problem. However, with e-cigarettes, the exposure will be chiefly from nicotine (a lower emission than from cigarette smoking is reported) and will exclude the toxic compounds from tobacco smoke such as carbon monoxide and other harmful organic volatile compounds. In any case the problem of second-hand exposure is not completely solved and hence as a premeasure the ban to smoke or vape in a number of public places or near a non-smoker/ non-vaper.

Smoking or/and Vaping

From the research results available so far, one is more inclined to say that e-cigarettes are less bad than smoking tobacco. Hence the reporting of a rise of e-cigarettes and a fall of smoking tobacco in the prevalent countries. There are people who may have shifted altogether from smoking to vaping. There are also those who are now both smokers and vapers. The shift could have been made in an attempt to quit or cut down on smoking or because it is cheaper. Does it work? Not really, as it has been reported that 90% of people have failed to quit.

The addiction is primarily due to nicotine and as outlined before is the main culprit common to both e-cigarettes and regular cigarettes. Some non-smoking adults and youngsters might try e-cigarettes out of curiosity. Other motives for re- sorting to e-cigarettes are recreational, or the influence of advertisements. Good projects in store for statisticians and epidemiologists to work on all these direct and comparative aspects of vaping and smoking!

Although nicotine is addictive, it is mainly tar that kills. Therefore, one argument would be to favour e-cigarettes as a means of harm reduction. However, one could only speculate on the percentage diminution of cancer deaths in users if there is a total shift to e-cigarettes. Another argument is whether e-cigarettes represent a gateway to re- gular smoking especially among teenagers and thus become a starting-point for nicotine use.

Also, unfortunately, the emergence of e-cigarettes has also offered cannabis users a new method of inhaling cannabinoids. In 2016, Public Health England (PHE) claimed that vaping is 95% less harmful than tobacco. And PHE even called for General Practitioners to be able to prescribe e-cigarettes on the National Health Service to help people quit smoking. Rather astonishing!

On the other hand, findings presented at a recent European Society for Cardiology Congress in Rome revealed that vaping could cause similar harm as smoking by damaging the aorta, which is the main artery of the heart. Although the long-term risks of vaping remain unknown, there could still be long-term dangers to the heart. The researchers in the meantime would not recommend the use of e-cigarettes.

Professor Charalambos, from the University of Athens Medical School, told the conference that he is not in favour of adopting e-cigarettes as a way to give up smoking and added that the United Kingdom has rushed into adopting this method. Despite being in use on the market for several years, regulatory agencies and health experts are not sure just how safe e-cigarettes are. However, it is known that e-cigarette users experience diminished lung function, increased airway resistance and cellular changes.

There could also be lack of disclosure of all the ingredients plus lack of validity of health and safety claims by manufacturers about their products. For example, the amount of nicotine on a cartridge label may not match the actual amount in the cartridge.

Local considerations

With easy and quick communication between Mauritius and the rest of the world, it can be assumed that e-cigarettes are already present on our land: either from visitors or natives who have brought them from abroad. They are all most probably using them privately. The Ministry of Health (MOH), who has always promoted campaigns against cigarette smoking and who constantly draws attention to the ill effects of smoking should now also be concerned about vaping and keep an eye on how widespread this new practice is in our country. To be forewarned is to be forearmed! With the help of the World Health Organisation, a perusal of the comprehensive FDA Legislation and also benefitting from long years of experience of other countries, the MOH should be in a position to take a wise decision in the very near future about all the issues related to e-cigarettes.

Concluding Remarks

With the advent of e-cigarettes, “NO VAPING” will inevitably have to be added in the not too distant future to the already well-acquainted “NO SMOKING” sign, as may be required! And, the best way to stop smoking or vaping is never to start!!

References

1. Chemistry World (Journal of the Royal Society of Chemistry) Volume 13 Issue 5 May 2016 Pages 22, 36, 48-52.
2. Wikipedia, the free encyclopaedia: e-cigarette
3. A. K. Jackaria: M.Sc (Forensic Science) Thesis University of Strathclyde (1974).
4. Liz Connor: 5 Simple Ways to give up Vaping and Smoking in The London Evening Standard 30 August 2016.
5. A Report of the Surgeon General, U.S. De- partment of Health and Human Services(2017): e-cigarette Use among Youths and Young Adults.