E-Cigarettes

E-cigarettes are devices that use batteries and a heating element to turn flavored liquids into a vapor that can be inhaled. Often marketed as a safer alternative to tobacco cigarettes, virtually all vaping liquids contain highly addictive nicotine. E-cigs, including JUUL, have been linked to seizures and other serious side effects.

E-cigarette vape pen
E-Cigarette Facts
  1. Uses Tobacco substitute, electronic nicotine delivery system
  2. Side Effects Nicotine addiction, seizures, lung diseases, strokes
  3. Manufacturers JUUL Labs, Altria-Philip Morris, British American Tobacco, Imperial Brands

Electronic cigarettes are more popularly known as e-cigarettes, e-cigs or vape pens. They include vape pens, vaporizers, e-pens, e-pipes, e-hookahs and e-cigars, which are all classified as electronic nicotine delivery systems (ENDS).

Products in this specific class deliver a liquid that contains a mixture of nicotine, propylene glycol, glycerin, flavorings (sometimes) and other unknown ingredients to users as a vapor instead of a harsher smoke.

E-cigarettes are now manufactured to look like everyday items, such as pens or USB memory sticks. There are hundreds of different e-cigarette brands currently available to consumers.

E-cigs were originally designed by a Beijing pharmacist, Hon Lik, in 2003, making the product a relatively new phenomenon. Lik was a heavy cigarette smoker. His father was also an avid smoker and died of lung cancer.

Lik’s purportedly safer-than-cigarettes alternative hit the U.S. and European markets in 2007. Manufacturers billed the devices as way to stop smoking and as a better option than tobacco cigarettes.

But one year after manufacturers started selling the electronic devices in the United States, the World Health Organization (WHO) urged marketers of the products to remove claims that e-cigarettes are a safe and effective way to quit smoking because no scientific evidence was available to support those claims.

Users have reported a growing list of potential e-cigarette side effects such as seizures, strokes and bronchiolitis obliterans organizing pneumonia.

Did You Know?
The FDA has not approved any e-cigarette as a smoking cessation aid, and there is no conclusive scientific evidence that e-cigs can help people stop smoking permanently.
Source: National Institute on Drug Abuse

In 2018, the U.S. Surgeon General declared an “epidemic of youth e-cigarette use.” He pointed to rapid increases in the number of teens using e-cigs and the dangers of nicotine to brain development in young people.

In November 2018, the U.S. Food and Drug Administration announced restrictions on the sale of flavored e-cigarette vape fluids. And in July 2019, the agency gave all e-cig makers 10 months to submit an application for FDA approval if they wanted to continue selling their products in the United States.

As of August 2019, several e-cigarette lawsuits had been filed in courts across the United States because of nicotine addiction and health problems blamed on the devices.

Is JUUL an E-Cigarette?

JUUL is the most popular e-cigarette marketed in the United States. The brand accounts for about 75 percent of all e-cigs sold. It is one of just five brands that control about 97 percent of the e-cigarette market. The other four are Vuse, MarkTen, Blu and Logic.

The trendy e-cigs appeal to young adults and teens who often don’t realize JUUL products are e-cigarettes or contain nicotine. Public health researchers even found teens using the term “juuling” instead of “vaping” to distinguish JUUL from other e-cigs even though the two activities are the same.

Juul E-cigs and pods
JUUL accounts for about 75 percent of all e-cigs sold.
Source: Wikimedia Commons

When JUUL first hit the market in 2015, its vape liquid contained much higher levels of nicotine than e-cigs that had already been on the market. Each JUUL pod contains as much nicotine as 20 regular cigarettes, according to the Centers for Disease Control and Prevention.

JUUL’s sleek design and addictive nicotine are credited for the device’s widespread popularity with teens and young adults, as well as JUUL’s rapid dominance of the e-cigarette market.

Who Uses JUUL and other E-Cigarettes?

Young people are more likely than adults to use e-cigarettes in the United States, according to the Centers for Disease Control and Prevention. The CDC reports that 2.8 percent of American adults used e-cigarettes in 2017.

Among adult e-cig users, 58.8 percent also continued to smoke tobacco cigarettes while 29.8 percent were former tobacco smokers. Another 11.4 percent of e-cig users had never been regular tobacco smokers.

Teen Use of JUUL and Other E-cigarettes

Teen use of e-cigarettes has increased rapidly since the introduction of JUUL in 2015. A 2018 report from Truth Initiative, an anti-smoking group, found that 15- to 17-year-olds were 16 times more likely to have used a JUUL e-cig than older age groups. The report also found more than half of JUUL users were younger than 18 the first time they tried the device.

The U.S. Surgeon General’s Office reports that about 20 percent of high school students used an e-cigarette in 2018.

Statistics About Youth E-cig Use
  • About 3.62 million middle and high school students used e-cigarettes in 2018.
  • From 2017 to 2018, e-cig use increased 78 percent among high school students and 48 percent among middle school students.
  • In 2018, 20.8 percent of high school students and 4.9 percent of middle schoolers reported having used an e-cigarette.

Source: U.S. Food and Drug Administration

How Do E-Cigarettes Work?

E-cigarettes come in a wide variety of shapes, sizes and designs, but they all work in pretty much the same way. They each have a mouthpiece, a battery, a heating element and a container for the vaping fluid, which is sometimes part of the mouthpiece.

E-Cigarette Cartridge

Cartridge

Holds the liquid mixture with varying dosages of nicotine, flavorings and chemicals

E-Cigarette Heating Device

Heating Device

To convert the liquid to a vapor (vaporizer)

E-Cigarette Power Source

Power Source

Usually a battery

When the user puffs on the e-cigarette’s mouthpiece, the battery-operated heating element activates. The heating element vaporizes the e-liquid stored in the cartridge and releases an aerosol or vapor, which the user inhales.

Nicotine Risks from JUUL and Other E-Cigarettes

Virtually all e-liquids used in JUUL and other e-cigarettes contain nicotine.

Nicotine is an addictive substance extracted from tobacco. Nicotine is what provides smokers and vapers alike with the feel-good, reinforcing properties that cause people to continue smoking or vaping even if they want to quit. E-cigarettes were designed to give people the same pleasurable feelings of smoking.

Open Pill Bottle Scattered on Table with Alcohol
Nicotine is thought to be a gateway to other addictive substances such as drugs and alcohol.

While nicotine itself is potentially harmful to a user’s health, nicotine addiction is the most immediate risk.

It takes just 10 seconds for nicotine to reach the brain after inhaling it. Nicotine causes the brain to release chemicals that make you feel pleasure. But over time, you may need more and more nicotine to get the same effect. You may also routinely need nicotine to ward off withdrawal symptoms. This can eventually lead to nicotine addiction.

E-cig users may switch to tobacco cigarettes to relieve their cravings. A 2017 study in JAMA Pediatrics found that 43 percent of high school students who used e-cigs with high nicotine content became frequent smokers within six months.

Nicotine in Teens and Young Adults

Nicotine carries serious risks for people under the age of 25.

“Any e-cigarette use among young people is unsafe, even if they do not progress to future cigarette smoking,” U.S. Surgeon General Jerome Adams said in his 2018 advisory on e-cigarettes and youth.

Nicotine Exposure Risks
Nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain.
Source: Centers for Disease Control and Prevention

The risks are largely due to nicotine’s effects on brain development. The human brain doesn’t finish developing until around the time people turn 25. Nicotine can interfere with parts of that development, causing permanent brain damage.

Nicotine can disrupt the part of the brain that controls attention, learning, moods and impulse control. People under the age of 25 are also more susceptible to becoming addicted to nicotine before the brain fully develops.

“Any e-cigarette use among young people is unsafe, even if they do not progress to future cigarette smoking.”

Source: Vice Admiral Jerome Adams, U.S. Surgeon General

Many teens may not know that they are ingesting nicotine when they use e-cigarettes. A 2019 study in the journal Pediatrics found that 4 in 10 teens inhaling nicotine-laced e-fluids thought they were using nicotine-free products. Researchers found these teens used e-cigs more frequently than others they studied. And they were inhaling as much nicotine as tobacco smokers without ever realizing it.

Since 2018, all newly-regulated tobacco products, including e-cigarettes, are required to display a warning statement on product packages and advertisements. The label reads: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”

A manufacturer can submit a statement to the FDA certifying that its product does not contain nicotine. But it then has to carry a different warning that reads: “This product is made from tobacco.”

Nicotine in Children and Pregnant Women

In 2016, the Surgeon General issued a report saying e-cigarettes are not safe. The report stated that the use of products containing nicotine in any form, including e-cigarettes, pose dangers — some with lasting consequences — especially to youth, pregnant women and fetuses. The report suggested e-cigarette side effects may be similar to those of other tobacco products.

The Surgeon General was especially concerned that e-cigarettes are marketed with an emphasis on flavors that can encourage e-cig use in youth and young adults. At the time, e-cigarettes, unlike traditional cigarettes, were not subject to age and marketing restrictions.

The federal age requirement for purchasing e-cigarettes is 18. But as of June 2019, at least 17 states had raised the age for purchasing e-cigarettes to 21.

Nicotine Deaths

The New York Times reported that it would take just a teaspoon of certain e-liquids to result in the death of a child if consumed.

The liquid is capable of resulting in acute nicotine toxicity if it comes into direct contact with a person’s skin or eyes, or if it’s ingested or even inhaled, especially in children, according to a study issued by the Centers for Disease Control and Prevention in 2015. The researchers found that children up to 5 years old accounted for 51 percent of e-cigarette exposure reports between 2010 and 2014.

A study conducted by the American Academy of Pediatrics in 2016 found:
  • From January 2012 to April 2015, the National Poison Data System received 29,141 calls for exposure to nicotine and tobacco products in children under six. That equates to an average of 729 children per month.
  • E-cigarettes accounted for 14.2 percent of exposures.
  • During the study, the monthly number of e-cigarette exposures increased by 1492.9 percent.
  • Children under 2 years old accounted for 44.1 percent of e-cig exposures.
  • E-cigarette exposures in children were 5.2 times more likely to be admitted to a medical facility.
  • Such exposures were also 2.6 times more likely to have a more severe outcome than those exposed to traditional cigarettes.
  • One death occurred from liquid nicotine exposure.

Source: Pediatrics

In December 2014, a 1-year-old child died from exposure to liquid nicotine. His was the first e-liquid-related infant death in the United States. But the number of reports of child exposures is rapidly increasing, according to the National Poison Data System. The CDC reported a significant increase in calls to poison control centers associated with growing e-cigarette use, up from 238 calls in 2011 to 3,692 calls in 2014.

According to the American Association of Poison Control Centers, there were 3,139 reports of e-cigarette and liquid nicotine poisoning cases reported in 2018.

But it’s not just children that can succumb to nicotine poisoning. The New York Times also reported that less than a tablespoon of e-liquids at higher concentration levels is capable of killing an adult, and one person was reported to have cardiac problems following absorption of the liquid through her skin.

Other Dangerous Chemicals in E-Liquids

It is difficult to determine what is in the thousands of different e-liquids sold for e-cigarettes. Part of that is because e-cigarettes have not been FDA-approved products. And there have been so many brands and flavors.

e-liquid components
Common components found in E-liquids.

But studies have identified chemicals used in e-liquids that can pose serious health risks. The dangers stem from a chemical reaction between the ingredients in the liquids.

A 2018 study in Nicotine & Tobacco Research found these reactions between flavorings and propylene glycol, which is used to make the vapor, can expose users to the same potential risks of tobacco cigarettes.

“Even in the absence of heating and combustion, chemical reactions are occurring in e-cigarette liquids and the resulting compounds could be harmful to the user’s airways,” researcher Hanno Erythropel told the American Journal of Managed Care.
 
Another 2018 study, this one in the journal Scientific Reports, found chemicals in vape fluid can combine to create various forms of formaldehyde, a naturally occurring chemical that has been linked to certain types of cancer in people with repeated exposure.

Researchers found that under normal vaping conditions, gaseous formaldehyde was produced at levels above those considered safe by the Occupational Safety and Health Administration.

E-Cig Flavoring

A 2015 study conducted by Harvard University researchers found that many different flavorings added to e-liquids in e-cigarettes contain chemicals that may be harmful to users’ long-term health.

Some flavors included in the study were: Classic, Menthol, Cherry Crush, Java Jolt, Pina Colada, Vanilla Bean, Bad Apple, Iced Berry, Banana, Pomegranate, Peach Pit, Watermelon, CooCoo Coconut, Pineapple Punch, Carmel Popcorn, Bubble Gum, Cotton Candy and Tutti Frutti.

Results showed that at least one of the three common flavoring chemicals — diacetyl, 2,3 pentanedione or acetoin — was present in 47 of the 51 flavors tested.

Harvard University E-Cig Flavor Study Results
  • Diacetyl was found in 39 of 51 flavors tested
  • 2,3-pentanedione was found in 23 of the 51 flavors
  • Acetoin was found in 46 of the 51 flavors
  • Diacetyl and 2,3-pentanedione were present simultaneously in 21 flavors tested
  • 2,3-pentanedione and acetoin were found simultaneously in 22 flavors

Source: Environmental Health Perspectives

Flavor Recalls

With hundreds of brands of e-cigarettes, over 7,000 different flavors and no FDA approval and no regulation until just recently, it’s difficult to track voluntary recalls or product modifications among manufacturers in the e-cig market.

In November 2018, JUUL suspended sales of most of its flavored pods in stores. Just days later, the FDA announced it would ban all e-cigarette flavors except tobacco, mint and menthol in retail stores. Fruity or sweet e-cig flavors can now only be purchased through age-restricted stores or online merchants that can verify a buyer’s age.

In August 2019, the FDA notified four companies to remove 44 flavored e-cigarette fluids and hookah tobaccos from sale in the United States. The agency crackdown underlined the FDA’s muscle-flexing on its authority to require FDA approval for new flavored products.

Explosion Recalls

Some brands of e-cigarettes have been known to overheat and possibly explode, resulting in burns (mostly in the mouth) and other severe injuries for e-cig users. The malfunction is likely due to the use of lithium-ion batteries to power the e-cigarettes.

Incidents of e-cigarette explosions have been reported to the U.S. Fire Administration dating back to 2009, just two years following the release of e-cigs into the U.S. market.

U.S. Fire Administration Findings on E-cigarette Fires & Explosions
  • 195 incidents of explosions and fires involving e-cigarettes were reported by U.S. media between January 2009 and December 2016.
  • These incidents resulted in 133 acute injuries.
  • 38 injuries were considered severe.
  • 121 fire and explosion incidents happened while the device was in a pocket or in use.
  • The shape and construction of e-cigarettes can make them more likely than other products containing lithium-ion batteries to act as “flaming rockets” as a result of battery failures.

Source: U.S. Fire Administration

The FDA has offered some recommendations to help e-cigarette users avoid potential battery malfunctions and explosions.

Vape Safety Infographic
Expand
Source: U.S. Food and Drug Administration

Please seek the advice of a medical professional before making health care decisions.

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Terry Turner
Written By Terry Turner Writer

Terry Turner has been writing articles and producing news broadcasts for more than 25 years. He covers FDA policy, proton pump inhibitors, and medical devices such as hernia mesh, IVC filters, and hip and knee implants. An Emmy-winning journalist, he has reported on health and medical policy issues before Congress, the FDA and other federal agencies. Some of his qualifications include:

  • American Medical Writers Association (AMWA) and The Alliance of Professional Health Advocates member
  • Centers for Disease Control and Prevention Health Literacy certificates
  • Original works published or cited in Washington Examiner, MedPage Today and The New York Times
  • Appeared as an expert panelist on hernia mesh lawsuits on the BBC
Edited By

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