Vaping likely has dangers that could take years for scientists to even know about

The rise in cases of otherwise healthy young adults who have been hospitalized or even died from vaping-associated lung
injury is alarming.

Many people don’t know what is contained in these vaping devices, what the reported health effects actually mean, and, most
importantly, why all of this developed so quickly, considering that e-cigarettes have only been popular for fewer than 10 years.

Vaping describes the process of inhaling aerosols generated by devices such as e-cigarettes.

When e-cigarettes first came to the U.S. in 2006, many smoking cessation experts were optimistic. They viewed the delivery of
nicotine through e-cigarettes to be a useful alternative to traditional cigarettes. That is because e-cigarettes did not have all of
the other harmful combustion products inhaled through cigarette smoke. Since there is no doubt that smoking traditional
cigarettes is harmful to your health – and the number one cause of preventable death in the U.S. – e-cigarettes were marketed
as a “safer” alternative.

As an inhalation toxicologist, I study how inhaled chemicals, particles and other agents affect human health. Since e-cigarettes
were introduced, I have been concerned about how the scientific community could possibly know the full spectrum of their
dangers. After all, it took decades for epidemiologists to discover that regularly inhaling the smoke from burning plant material,
tobacco, caused lung cancer. Why would the scientific community be so quick to assume e-cigarettes would not have hidden
dangers that might take years to manifest too?

Many smokers have reported that switching from cigarettes to e-cigarettes has helped their physical well-being,
including reduced coughing.

But a few randomized clinical trials examining the use of e-cigarettes as a cessation tool have shown mixed results. While some
trials demonstrate a significant increase in cessation success (from 9.9% to 18%), people using e-cigarettes were much more
likely to remain dependent on nicotine as compared to those randomized for more traditional nicotine replacement products,
such as nicotine patch, gum and nasal spray. Or, they were more likely to relapse to using cigarettes.

In short, whether, how, and to what extent e-cigarettes have potential as a cessation tool is not yet settled, especially
considering that more than 80% of smokers randomized to use e-cigarettes continued to smoke after the cessation trial.

Cessation claims aside, the messaging of e-cigarettes as a “safer” alternative may have led many of the 3.6 million teenagers in
the U.S. who use e-cigarettes today to believe these devices are “safe.” “Safer” does not equal “safe,” and the messaging of
“safer” was based on comparisons to cigarettes.

Public Health England, the equivalent of the FDA in the U.K., stated in 2015 that “while vaping may not be 100% safe, most of
the chemicals causing smoking-related disease are absent and the chemicals that are present pose limited danger.”

This statement did not consider the fact that health effects of inhaling flavoring chemicals contained in popular e-cigarettes are
completely unknown, or that heating liquids in these devices causes thermal decomposition of those e-cigarette chemicals that
“pose limited danger” into known toxicants. It also did not consider that e-cigarettes are a fast evolving consumer product with
ever-changing devices and chemicals, creating mixtures and exposures of unknown health consequences.

This mistake was further advanced by assessing the adverse health effects caused by using e-cigarettes as a comparison to what
occurs when someone smokes cigarettes for several years. It is well established that smoking cigarettes causes diseases such
as chronic obstructive pulmonary disease, chronic bronchitis, emphysema and cancer. Many of these diseases do not manifest
clinically until many years after the first cigarette has been smoked.

No controlled studies were ever conducted assessing whether using e-cigarettes causes any adverse health effects in people
who never smoke. To this day, scientists do not know the potential long-term health consequences of using e-cigarettes for
decades.
I think that scientists and policymakers should completely stop comparing vaping outcomes to smoking outcomes. The now
380-plus cases of vaping-associated lung injuries prove this point. The clinical manifestations in these patients are not
something a doctor would ever see in somebody who has been smoking cigarettes for a few months.

Similarly, these clinical outcomes have not been reported in marijuana users, even though THC, the psychoactive ingredient in
marijuana, has now been associated with a large percentage of these cases.

Furthermore, the onset of these significant health problems is much faster than one would anticipate from smoking-related
diseases. Since doctors are seeing severe diseases after relatively short exposures, does that make vaping more harmful than
cigarettes?

Considering that the compounds inhaled through cigarette smoke are very different from those inhaled through the vast
number of different flavored e-cigarettes and vaping devices, wouldn’t that be like comparing apples and oranges? Nobody
would consider it reasonable to compare health effects caused by smoking cigarettes to those induced by smoking crack.

A lot of attention is now being placed on identifying the potential “culprit” for the observed health effects in the more than 450
cases of vaping-induced lung injury. Additives contained in THC liquids have emerged as a potential cause.

However, not all cases identified by the CDC have a documented history of vaping THC, and some have only reported a history
of using nicotine products. Furthermore, case reports of vaping-associated lung injury with symptoms similar to those reported
by the Centers for Disease Control and Prevention but no history of THC use have been documented before, suggesting that
vaping-associated lung injury has been detected before this recent rise in reported cases.

In addition, other vaping-associated clinical outcomes have been reported as well, indicating that vaping-induced adverse
health effects can vary. Hence, it is premature to draw any conclusions regarding which compounds – and there are likely
several – inhaled by vaping nicotine or THC containing products are causing specific types of lung injury.

While it is too early to say whether or to what extent e-cigarettes can be used to support smoking cessation, one conclusion can
already be drawn: Vaping is not without health effects.

Some Flavored E-Cigarettes Contain Cancer-Causing Chemical

Electronic cigarettes flavored with mint and menthol may contain high levels of a potentially cancer-causing chemical that's
banned from food in the U.S., according to a new study.

The finding comes just days after President Donald Trump's administration proposed banning flavored e-cigarettes following a
string of mysterious vaping-related illnesses across the country.
Pulegone is an oil extracted from mint plants such as peppermint and spearmint that was previously added to candies and
chewing gum to give flavor. Last year, the Food and Drug Administration (FDA) banned synthetically made pulegone as a food
additive because of carcinogenic effects found in animal studies.

Related: 4 Myths About E-Cigarettes

However, there is a "discrepancy in regulation of the chemicals in food versus e-cigarettes," said study co-author Sven Jordt, an
associate professor in anesthesiology, pharmacology and pathobiology at Duke University's School of Medicine. For e-
cigarettes, the FDA's "level of regulation is fairly minimal."

Indeed, several Centers for Disease Control and Prevention (CDC) studies previously found high levels of pulegone in mint- and
menthol-flavored e-cigarettes and smokeless tobacco. "The fact that it's allowed in e-cigarettes is very concerning," Jordt told
Live Science.

For the new study, the researchers analyzed how much risk came with inhaling or ingesting pulegone. They calculated what's
called the "margin of exposure" — a measure used by the FDA to calculate the cancer risk posed by food additives — for
people who smoked various levels of flavored e-cigarettes and used smokeless tobacco.
To do that, the researchers used data obtained from the FDA about what levels of pulegone exposure were low enough to
avoid causing tumors in animal studies. (Similar studies in humans don't exist.) The researchers also examined data obtained
from the CDC on the amount of pulegone people were exposed to on average when using various products.

The FDA deems a product safe for consumption if its margin of exposure (which is expressed as a ratio) is 10,000 or above. In
other words, they say a food additive is safe when its concentration in food is 10,000 times lower than what would cause
cancer in animals such as rats.

The researchers calculated the margin of exposure for five different brands of menthol- and mint-flavored e-cigarettes and one
brand of smokeless tobacco. They then compared the levels to that of menthol cigarettes.

In the results, the margin of exposure for people smoking or consuming smokeless tobacco that contains pulegone ranged from
325 (in the heavy users) to 6,012 (in the light users) — much higher than the safety margin. What's more, people who smoked
flavored e-cigarettes or consumed smokeless tobacco were exposed to much higher levels of pulegone than those who smoked
menthol cigarettes, which have largely reduced levels of pulogene compared to what they contained in the 1970s, Jordt said.

"Levels by far exceeded [the] amount FDA was considering safe," Jordt said. "Users may eventually develop cancer based on the
risk we found." That would, of course, not happen immediately, but over the course of many years. Now, Jordt and his team are
exposing human lung cells in a lab dish to pulegone to see if the compound damages the cells. "We are also approaching the
CDC and FDA about this data," he said.

The findings were published today (Sept. 16) in the journal JAMA Internal Medicine.

Trump Administration Plans to Ban Flavored E-Cigarettes

Flavored electronic cigarettes may soon be banned in the United States, according to news reports.

Today (Sept. 11), the Trump Administration announced that it plans to finalize a policy that would remove non-tobacco-
flavored e-cigarettes, such as mint and menthol flavors, from the U.S. market.

"The Trump Administration is making it clear that we intend to clear the market of flavored e-cigarettes to reverse the deeply
concerning epidemic of youth e-cigarette use that is impacting children, families, schools and communities," Health and Human
Services Secretary Alex Azar said in a statement.

When the new plan goes into effect in the coming weeks, it would result in the removal of flavored e-cigarettes within 30 days,
according to Bloomberg News. After that, companies that want to market flavors of e-cigarettes besides tobacco would need to
apply to the Food and Drug Administration for approval of their product. The manufacturers of these flavored vaping products
would need to prove that the risks of the products, such as their potential for use by teens, are outweighed by its benefits,
Bloomberg reported.