It is very interesting how certain fruity or other favorite flavors of childhood are often seen as safe, even when we are inhaling them. Many seem to think that just because something is safe to eat or rub on our skin, it should be safe to inhale. But this is actually not true- as food passes through our saliva and into our intestines, our body actually has a whole host of ways it can remove toxins. The chemicals from the food then enter our bloodstream, and they first go through our liver, which has an armada of enzymes that also further eliminate the toxic chemicals or threats in what we are eating. Our lungs have none of that. When we inhale things, they get very quickly into our bloodstream without any of those defenses against them.
The flavors that are in e-cigarettes are often recognized as safe to eat, but the trade association of the flavor manufacturers have identified that over 1000 of their flavoring agents are potential respiratory hazards. Nevertheless, e-cigarette users often think that they think they are safe to inhale if they are being sold.
In terms of vaping and e-cigarettes, people may be familiar with the “E-cigarette and Vaping Associated Lung Injury” epidemic from 2019, but damage to the lungs was not limited to 2019 alone. Two of my partners described a case of lung scarring or interstitial lung disease that developed in someone after 7 months of e-cigarette use back in 2012.
For this podcast episode and post, I talked to Professor Ilona Jaspers, PHD, of the departments of pediatrics, microbiology and immunology, environmental sciences and engineering at the University of North Carolina at Chapel Hill. She is also the director there for the curriculum in Toxicology and environmental medicine. She studies a host of toxins that affect the lungs, from air pollution to inhaling flavoring chemicals.
She has researched the effects of flavors on the lungs, and also the effects of the newer fourth generation nicotine devices, and found that these have signs of increased airway damage in the lungs of those who use them. Furthermore, they seem to change the immune system of the lungs in a way that likely leads to worsened immune function, which has been studied previously. We do know that people who smoke or use e-cigarettes are at increased risk of severe COVID, and smokers have an increased risk of fulminant lung injury called Acute Respiratory Distress Syndrome.
In one study of inhaling cinnamon flavors, they took cinnamon flavored e-liquids they obtained from a local vape shop and delivered them with e-cig devices to lung cells and evaluated what happened. It is disturbing. A very important part of our lung immune system are tiny cellular hairs or cilia that move continuously to clear mucus, debris, particulates and more from our lungs. The cinnamaldehyde poisoned them as the dose of inhaled cinnamon flavor increased.
The power houses of the cell, the mitochondria, were also damaged at increasing doses of the cinnamaldehyde mixture. The concentrations they used were all in the range of what is contained in regular flavored e-cigarette devices.
I sincerely enjoyed talking to Professor Jaspers. She has dedicated her career to understanding how what we breathe affects our health. One significant challenge with these fruity e-cig and vaping devices is that they are sold and advertised everywhere. The neighborhood store where I go with my kids to get paletas, a delicious type of ice cream with many wonderful flavors, sells them immediately next to a wide variety of vaping and e-cig devices advertising the same flavors at eye level to my kids. I think kids (and often adults) often assume that if something is being sold to use that it should be safe to use. I have been active in trying to prohibit those types of sales. I had a young teen patient who became profoundly ill and was hospitalized from e-cig lung damage after buying these devices regularly at corner stores. She said they never carded her, despite the legal age to purchase them being 21 in my state.
It is a challenge, because prohibiting the sale of flavored devices at physical locations may not shut down the online sale to those who are already addicted to nicotine. However, I do think it will help slow the pipeline of child clients for these devices and help those struggling to avoid them. We know that prohibiting the sale of flavored cigarettes in general decreased youth use over the long term. It will be interesting to see what happens over time in states that do have comprehensive flavor bans. I was heartened recently to talk to someone in their 20s who does use flavored e-cigarettes. She wants to quit, and when she traveled to a location with a flavor ban recently and couldn’t find her flavor, she just decided not to buy any nicotine products. So far, the long term data about removing flavors from being mixed with nicotine is in general heartening to me in terms of stopping the addiction of new tobacco industry clients. Providence, Rhode Island banned the sale of flavored tobacco products except mint or menthol flavors. Of course, Big Tobacco sued but eventually the policy went into effect. Following this, there was a decrease in tobacco use in high school students- with any use of tobacco products being cut from 22.1% to 12.1% from 2016 to 2018. E-cig use also decreased from 13.3% to 6.6%, and both of these rates were lower than the rates in the rest of the state that did not have a flavor ban. The business model of Big Tobacco is to addict these kids before the age of 21, so policies that help prevent that initial addiction are key.
It is important to help people break free of inhaling tobacco products (or honestly, inhaling anything but good clean air if at all possible!) Combustible tobacco is very deadly. I want to do all I can to help my patients break free of this, and most of them want to. I agree with Professor Jaspers that switching to an e-cigarette device to help quit smoking may be a harm reduction strategy, and I help patients do that if they prefer it or if other ways of quitting haven’t worked for them. I do worry that if people switch to a cooling or flavored device, that they will continue to use it longer, increasing their risk for all the potential downstream health problems from these devices. Even if they continue to use an e-cigarette because they really can’t or don’t want to quit inhaling nicotine, at least they won’t have the additional toxicity of the flavors.
There are also flavored nicotine products that are likely much safer, such as flavored nicotine gums and lozenges. As Professor Jaspers says, it’s the route that often makes the poison, and the lungs have minimal defenses to these inhaled chemicals compared to our intestinal tract. If people really do find the mix of flavor and nicotine potent, gums and lozenges are likely the much safer choice.
These are very hard conversations to have at the individual and policy level. I am passionate about advocating for my patients who are struggling with an addiction to nicotine. Most adult smokers want to quit, and the tobacco industry has done all it can to make it very hard. They addict people when they are young, overwhelmingly by the use of flavored products, and fight tooth and nail with very deceptive tactics about freedom and more to keep their products in the line of sight. A great deal of “whataboutism” starts to crop up when you try to address tobacco, including other drugs, alcohol, etc. I honestly think there needs to be higher scrutiny and regulation of chemicals that are going to go straight into the bloodstream- which is essentially what happens when someone inhales a chemical. The lungs are designed to pull oxygen out of the air and put it straight in our bloodstream. This inhalation can bring many chemicals along for the ride. Flavoring chemicals probably shouldn’t be one of them.
To Do:
1- If you have a young person in your life age 10 and up, listen to the first episode from the season, #DotheVapeTalk to learn about how to have these conversations. You can also go to talkaboutvaping.org for more resources. You can learn more about what different e-cigarettes might look like here.
2- If you are struggling to quit inhaling nicotine, whether from combustible or electronic cigarettes, check out the “Quit, Don’t Switch” campaign from the American Lung Association for other resources to help quit smoking.
3- If you really don’t want to or can’t quit, and want to try an e-cigarette for potential harm reduction, in general avoid inhaling flavored ones if possible.
4- Read the “Get the Facts” guide from the ALA. If you want more details on the specifics of e-cigarette biology, listen to the “Gambling with your lungs” episode with Dr. Jeff Gotts from Season One.
5- If you want to get involved on the policy side, listen to the “A Teen Talks Vaping” episode about tobacco retail licensing and ensure there is robust tobacco retail licensing in your community.
6- For more on the dangers of flavors and their history, especially among kids and in the black community, listen to “A Heartbreaking Trap” and “A County vs Big Tobacco.” You can learn more about the specifics of flavor dangers at airhealthourhealth.org/FlavorFree.
