Clearing the smoke: Often buried truths about e-cigarette use

November 15 was pivotal—it marked the day when the first case of electronic cigarette or vaping product use associated lung injury (EVALI) was recorded in the Philippines. The diagnosed patient, aged 16, was said to only have started using electronic cigarettes (e-cigarettes) in March of this year. This news came amid a slew of 2,290 similar cases in the United States, which were initially detailed by the Centers for Disease Control in a report that also advised exercising caution when using e-cigarettes.

In retrospect, it has been 16 years since the first e-cigarette saw commercial release—emerging as a venture to test whether cigarette smokers would quit their vice when presented with a “healthier option”. Now, one million Filipinos—about one percent of the country’s total population—are recorded as users of e-cigarettes. If trends follow the aforementioned EVALI outbreak in the United States, a national EVALI epidemic may similarly lurk in the future of Filipino communities.

Controls and regulations

Currently, whether inside or outside the University, both consumers and non-consumers of e-cigarettes are monitored and regulated by legislations and policies.

On a nationwide scale, the Department of Health (DOH) is responsible for overseeing public health-related concerns of the Filipinos. The Food and Drug Administration’s (FDA) Center for Cosmetics Regulation and Research serves as its research-based policy making arm, as its scope encompasses regulating the use of and monitoring related research on e-cigarettes.

Meanwhile, the Student Discipline and Formation Office fulfills a similar role in the Lasallian community. Stipulated in Section of the Student Handbook, the No Smoking Policy—which covers all members of the academic community—emphasizes that the use of either traditional or e-cigarettes “inside University premises, along Agno and F. Reyes Sts. until E. Razon Sports Complex Bldg., and within five meter periphery from gates, fences, and dividing walls of the campus, or outside the University during academic functions or school activities” merits a minor offense.

With regard to the implementation of the rule, however, some students like Puck* (I, PSM-MKT) feel that there should be a “stricter” check on members of the University. “Those caught smoking within the [perimeter] with a school ID on should be considered a violator of the Handbook rule and of Executive Order (EO) No. 26,” Puck proposes.

Aside from the mentioned EO which mandates a nationwide smoking ban, the DOH also released an administrative order (AO) banning the public use of e-cigarettes, including vape pens and Juul. This AO was then suspended due to a temporary restraining order (TRO), following a case appealed by private groups against the supposed e-cigarette ban.

President Rodrigo Duterte, however, ordered for the arrest of e-cigarette users through a public mandate last November 19 without passing any new executive order, in effect overstepping the supposed TRO.

(Also) bad for you

E-cigarettes are differentiated from traditional, tobacco-based cigarettes in that the former contains e-liquids, while the latter rely on the burning of cured tobacco leaves. E-liquids typically contain nicotine—the same addictive substance found in traditional cigarettes—as well as flavorings and a humectant, which is a hygroscopic or water-absorbing substance used to keep the contents moist.

Whenever the tobacco in a traditional cigarette is burned, highly toxic tar is produced as a residue. This tar contains 7,000 identified chemicals—250 of which have been deemed harmful to human health, with 60 of them being known carcinogens, or substances capable of inducing the cancerous growth of cells.

E-cigarettes, on the other hand, do not produce tar as their delivery mechanism is via aerosolization, which involves converting the e-liquids into a fine mist. These e-liquids, however, are “scarcely regulated beyond their nicotine content,” owing in part to manufacturers’ claims of using only food grade ingredients.

This line of thinking, however, is flawed, as pointed out by Dr. Anton Javier—Project Manager of the Product Research and Standards Development Division of the Center for Cosmetics Regulation and Research of the FDA—in an interview with The LaSallian. “When you say food grade, that’s safe for eating—that’s not necessarily safe for inhalation,” Javier explains. “Your lungs are a very different kind of organ as compared to your digestive system. Your digestive system is built to withstand these chemicals, but your lungs are a totally different issue.”

When heated, sugars and humectants can undergo chemical reactions that have by-products such aldehydes, acrolein, and formaldehyde—many of which are carcinogenic. Flavorings, too, are not off the hook. Prolonged exposure to some can be dangerous, with various diseases arising as possible consequences, including bronchiolitis obliterans. Javier describes the condition as “a constriction of the [lungs’] airways that happens when [one takes] in varying levels of diacetyl,” a chemical that gives food a
buttery taste.

Aerosolized e-liquids are not the only hazards to the health of e-cigarette users—even the heating coils inside the e-cigarettes can be a source of risk, too, Javier reveals. “Common materials used in e-cigarettes include kanthal, which is an alloy of iron, chromium, aluminum, and nichrome which [combines] nickel and chromium,” he notes, adding that some studies have detected the presence of these  metals in the emissions or smoke emitted by e-cigarette products.

The FDA representative continues, “Sometimes, the chromium [in the coils] leaches out [into the emissions], and is inhaled by consumers; this could potentially result in cellular injury.”

E-cigarettes and the youth

As e-cigarettes were initially conceived as an alternative to draw smokers away from smoking tobacco-based cigarettes, the elephant in the room must be addressed—rampant e-cigarette use among the youth, to which Javier expresses dismay. He laments, “The positive effects of e-cigarette availability have been made less significant…The current wave of nicotine addiction among teens is more associated with e-cigarettes than with classic cigarettes.”

Javier discusses that early exposure to nicotine can lead to maldevelopment of the prefrontal cortex, the region of the brain that handles executive functions such as planning, emotion regulation, and attention. He adds, ”Due to the nature of brain development, for those under 25, exposure to nicotine will impair their ability to control their emotions—their urges—for life.” Given this, e-cigarette use can become a gateway for youths to explore other dangerous substances or perpetuate delinquent behaviors because, as Javier puts it, individuals who start out smoking or vaping “are far more impulsive; they have less self-control, and they’re more likely to act on their emotions rather than their better judgement.”

Considering that a 2018 survey conducted by the National Institutes of Health found that close to one-third of American 12th graders have used e-cigarettes, and a 2015 survey by the DOH observed that over one-tenth of Filipino children aged 13 to 15 have used e-cigarettes, there is evidently much cause for concern.

Varying viewpoints

In an online survey administered by The LaSallian to 71 individuals, 96 percent of the e-cigarette smokers among the respondents maintain that they are “well aware” of the health risks and hazards posed by using e-cigarettes.

Some respondents reveal that smoking or vaping is their preferred coping mechanism when dealing with psychological distress; as Reese* (IV, AB-CAM) discloses, “I use e-cigarettes because I feel they’re a way for me to cope with anxiety.”

Furthermore, less individuals believe that vaping is “100 percent safer” as compared to smoking traditional cigarettes.

“Studies show that breathing indoors is worse than breathing vapor from e-cigarettes. Health risks only come from [traditional] cigarettes because of chemicals [they contain],” asserts Frederico* (III, ECE2). Enrico* (II, BSINSYS) shares a similar viewpoint, insisting that there is “no significant risk in using quality vape products”.

In contrast, most of the non-smoker respondents express disagreement on the use of e-cigarettes and vaping, emphasizing its contribution to air pollution and their concerns regarding secondhand smoke, which is exhaled by a smoker or emitted by an e-cigarette.

Despite wanting a complete ban of e-cigarettes, Mar Winston (II, AB-PSM) acknowledges that addiction to these prevents smokers from quitting immediately. Instead, he suggests, “The government should impose areas for smokers that is far from non-smokers in order for [the latter] not to inhale [the emissions]. There should also be a rehabilitation center that is accessible for everyone.”

*Names with asterisks (*) are pseudonyms.

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