E-cigarettes and Lung Health

What Are E-cigarettes?

Electronic cigarettes, or e-cigarettes, include e-pens, e-pipes, e-hookah, and e-cigars are known collectively as ENDS – electronic nicotine delivery systems. According to the FDA, e-cigarettes are devices that allow users to inhale an aerosol (vapor) containing nicotine or other substances.

Unlike traditional cigarettes, e-cigarettes are generally battery-operated and use a heating element to heat e-liquid from a refillable cartridge, releasing a chemical-filled aerosol.

What Are in E-cigarettes?

The main component of e-cigarettes is the e-liquid contained in cartridges. To create an e-liquid, nicotine is extracted from tobacco and mixed with a base (usually propylene glycol), and may also include flavorings, colorings and other chemicals.

Following the 2016 announcement allowing FDA oversight of tobacco products, e-cigarette manufacturers must register with FDA by August 8, 2016, and then will have two additional years to submit an application to remain in the marketplace.  Until that time, the nearly 500 brands and 7,700 flavors of e-cigarettes will remain on the market – before FDA is able to fully evaluate them.  Until FDA's evaluation is done, there are very few ways for anyone other than the manufacturers to know what chemicals are contained in e-liquids, or how e-cigarette use might affect health, whether in the short term or in the long run.

Initial studies show that e-cigarettes contain nicotine and also may add in other harmful chemicals, including carcinogens and lung irritants.

Nicotine
Nicotine is an addictive substance, and almost all e-cigarettes contain nicotine. Even some products that claim not to have any nicotine in them may still contain it. For instance, initial FDA lab tests conducted in 2009 found that cartridges labeled as nicotine-free had traceable levels of nicotine. A 2014 study found little consistency in the amount of nicotine delivered by e-cigarettes of the same brand and strength.¹ Similarly, another 2014 study found that the amount of nicotine in e-liquid refills is often substantially different from the amount listed on the package.²Experienced users learn how to use e-cigarettes in a way that increases their exposure to nicotine. Newer e-cigarette devices, especially "tank" styles, with higher voltage also deliver a greater concentration of nicotine. This matters because the more nicotine used, the greater the potential for addiction.

Nicotine is not safe. The U.S. Surgeon General has found exposure to nicotine during pregnancy harms the developing fetus, and causes lasting consequences for the developing brain and lung function in newborns. Nicotine exposure also affects maternal and fetal health during pregnancy, and can result in low birth weights, preterm delivery and stillbirth.

Nicotine also has a negative impact on adolescent brain development. Human brain development continues far longer than was previously realized, and nicotine use during adolescence and young adulthood has been associated with lasting cognitive and behavioral impairments, including effects on working memory and attention.

Other chemicals
We don't presently know what is in e-cigarettes. However, in initial lab tests conducted in 2009 the FDA found detectable levels of toxic cancer-causing chemicals, including an ingredient used in anti-freeze, in two leading brands of e-cigarettes and 18 various cartridges. A review of studies found that levels of toxins in e-cigarette aerosol varied considerably within and between brands. A 2014 study found that aerosol from e-cigarettes with a higher voltage level contains more formaldehyde, another carcinogen with the potential to cause cancer. The findings are alarming, and underscores why the American Lung Association called so urgently for FDA oversight of these products.

Flavors in e-cigarettes are also a cause for concern. Not only are flavors used to target kids, but they may be harmful on their own. E-cigarette and flavor manufacturers and marketers may suggest that the flavor ingredients used in e-cigarettes are safe because they have FEMA GRASTM status for use in food, but such statements are false and misleading. The reality is that FEMA GRASTM status only applies to food, meaning it's safe to eat, and does not apply to inhaling through e-cigarettes. 

Diacetyl, a buttery flavored chemical often added to food products such as popcorn, caramel, and dairy products, has also been found in some e-cigarettes with flavors. Diacetyl can cause a serious and irreversible lung disease commonly known as "popcorn lung."

Poisoning concern
Aside from concerns about e-cigarette use and emissions alone, data released by the Centers for Disease Control and Prevention (CDC) shows that calls to the nation's poison centers for e-cigarette exposure poisonings are rapidly increasing. One study found that while most calls involving e-cigarette liquid poisoning came from accidental ingestion of the e-cigarette or its liquid, about one-sixth of the calls related to someone inhaling these items. Exposure through the eye and the skin were also reported.

Large doses of nicotine have a potential for poisoning, with symptoms beginning with nausea and vomiting in cases of acute toxicity and progressing to seizures and respiratory depression in cases of severe nicotine poisoning. This is particularly true in children as calls to poison control centers have increased nationwide. Tragically, one child died from acute e-cigarette poisoning in 2014, attributed to the ingestion of liquid nicotine from an e-cigarette.

The article from -- AMERICAN LUNG ASSOCIATION