Electronic or conventional cigarettes – which is safer?

This article was exclusively written for The European Sting by Ms. Mariana Marçal, a 23-year-old medical student from Lisbon, currently attending the 4th year at NOVA Medical School. She is affiliated to the International Federation of Medical Students Associations (IFMSA), cordial partner of The Sting. The opinions expressed in this piece belong to the writer and do not necessarily reflect IFMSA’s view on the topic, nor The European Sting’s one.

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When it was suggested back in 1939 that cigarettes were a responsible factor for the rise in lung cancer, this idea seemed laughable at the time. Today, it is well established that tobacco is harmful and is strongly linked to cancer [1]. The recent rise in alternative products such as electronic cigarettes, however, has led to uncertainty about its true long-term effects on health. Electronic cigarettes (or e-cigarettes) are battery-operated devices that electrically heat and vaporize “e-liquids” to produce inhalable vapours without combusting tobacco. E-cigarettes started being commercialized in 2003 in China and entered the European markets in 2006. These products present a challenge for public health due to their alarming increase in popularity. In 2017, about 15% of the European population had tried e-cigarettes at least once in their life [2]. Another study from the US showed that between 2017 and 2018, the number of high school students that reported current use of e-cigarettes increased from 12% to 21% [3]. Evidence suggests that e-cigarettes are being used among teenagers for alternative behaviours such as dripping, smoke tricks, use of flavours, and use of other substances such as marijuana [4]. The effects of chronic use of e-cigarettes are still largely unknown, and levels of toxic and carcinogenic compounds may vary greatly depending on the brand. Many e-cigarettes contain misleading or missing information on product ingredients, but across all brands, the main components are nicotine, propylene glycol, glycerol, and flavourings. Many studies found other harmful substances such as metals, carcinogenic tobacco-specific nitrosamines and carbonyls [5]. E-cigarettes do not produce the tar that is contained in traditional cigarettes. However, studies have found that it produces formaldehyde, acetaldehyde and acetone a known carcinogen at levels above recommended levels [6]. The overall health risks associated with e-cigarettes remain uncertain but they cannot be considered safe. A recent study found daily e-cigarette use is associated with increased risk of myocardial infarction [7]. In 2018, a study of mice found that e-cigarette smoke could cause mutations in DNA that could increase the risk of cancer [8]. However, we remain shockingly ignorant about the toxicity of chronic exposure to these products. E-cigarettes have been widely marketed as a tool for smoking cessation and a safer alternative to conventional cigarettes. Although some small studies suggest that e-cigarettes could be an effective strategy to quit smoking in some people [9], there are no large, high-quality studies to support this claim thus far. There are also some concerns that e-cigarette use may be a gateway to nicotine dependence among adolescents. In 2016, the World Health Organization (WHO) urged countries to restrict the sale, promotion, and use of electronic cigarettes [10]. Overall, more research is needed in order to compare the risks and long-term effects of e-cigarettes with tobacco products. As a society, we need to get ahead of this real public health issue. More regulation and restrictions are needed, as well as an international effort to make new policies, promote more research and educate citizens on this issue. References [1] Viswanath, Kasisomayajula, et al. “Tobacco and Cancer: An American Association for Cancer Research Policy Statement.” Cancer Research, American Association for Cancer Research, 1 May 2010, cancerres.aacrjournals.org/content/70/9/3419. [2] Special Eurobarometer 458 – Attitudes of Europeans towards tobacco and electronic cigarettes. Available at http://ec.europa.eu/commfrontoffice/publicopinion/index.cfm/Survey/getSurveyDetail/instruments/SPECIAL/surveyKy/2146. (accessed 25th April 2019) [3] Cullen, Karen A., et al. “Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018.” MMWR. Morbidity and Mortality Weekly Report, 2018, doi:10.15585/mmwr.mm6745a5. [4] Krishnan-Sarin, Suchitra, et al. “E-Cigarettes and ‘Dripping’ Among High-School Youth.” Pediatrics, vol. 139, no. 3, 2017, doi:10.1542/peds.2016-3224. [5] Orellana-Barrios, Menfil A., et al. “Electronic Cigarettes—A Narrative Review for Clinicians.” The American Journal of Medicine, vol. 128, no. 7, 2015, pp. 674–681., doi:10.1016/j.amjmed.2015.01.033. [6] Kosmider, Leon, et al. “Carbonyl Compounds in Electronic Cigarette Vapors: Effects of Nicotine Solvent and Battery Output Voltage.” Nicotine & Tobacco Research, vol. 16, no. 10, 2014, pp. 1319–1326., doi:10.1093/ntr/ntu078. [7] Alzahrani, Talal, et al. “Association Between Electronic Cigarette Use and Myocardial Infarction.” American Journal of Preventive Medicine, vol. 55, no. 4, 2018, pp. 455–461., doi:10.1016/j.amepre.2018.05.004. [8] Lee, Hyun-Wook, et al. “E-Cigarette Smoke Damages DNA and Reduces Repair Activity in Mouse Lung, Heart, and Bladder as Well as in Human Lung and Bladder Cells.” Proceedings of the National Academy of Sciences, vol. 115, no. 7, 2018, doi:10.1073/pnas.1718185115. [9] Kulik, Margarete C., et al. “E-Cigarettes Associated With Depressed Smoking Cessation: A Cross-Sectional Study of 28 European Union Countries.” American Journal of Preventive Medicine, vol. 54, no. 4, 2018, pp. 603–609., doi:10.1016/j.amepre.2017.12.017. [10] WHO Report to COP7 on ENDS/ENNDS. Available at http://www.who.int/tobacco/communications/statements/eletronic-cigarettes-january-2017/en/. About the author Mariana Marçal is a 23-year-old medical student from Lisbon, currently attending the 4th year at NOVA Medical School. In 2018, she joined Education Against Tobacco (EAT), an international non-governmental organisation run entirely by volunteer medical students and physicians from over 80 medical schools around 14 countries, whose work focuses mainly on school-based prevention of tobacco use. She is now the head of Scientific Department at her school’s EAT group and hopes their work reaches more students and further expands across more schools and countries.