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Electronic Cigarettes and Why the Concern

Submitted by

David Axt, Pharmacist

LCO Community Health Center

Great strides have been made to reduce cigarette smoking in the United States, but Native Americans have been left behind. Since the 1964 landmark Surgeon General report, Smoking and Health1, the prevalence of adults who smoke has gradually declined from 51% of men and 33% of women in 19642 to 14% for all adults in 20173. Unfortunately, the prevalence of American Indian/Alaskan Native adult smokers is still at 34%4 and as high as 60% among Minnesotan American Indians5. Electronic cigarettes are a risk to this progress. The use of e-cigarettes by high school students has risen 14-fold from 2011 (1.5%)6 to 2018 (20.8%)7. Native people have been left behind health progress forever and are at risk for more losses from the electronic cigarette epidemic.

Electronic cigarettes are also known as “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems.”

The anatomy of electronic cigarettes is relatively simple. E-cigs have a rechargeable battery to heat metal coils inside a chamber which holds a liquid (“juice”) containing nicotine, propylene glycol, vegetable glycerin, and flavorings. The generation of the inhaled vapor requires heating of the liquid on the hot coils. The toxicity of the vapor is the result of chemical changes after cooking the liquid to 400-475 degrees Fahrenheit.

The risks of e-cigs are varied. The primary long term risk is to our youth who are getting the message that cigarettes are harmful, but are now hearing myths from manufacturers that e-cigs are “safe”. The high doses of nicotine delivered by electronic cigarettes mimic the nicotine blood levels from smoking cigarettes8 and can deliver much more nicotine than from conventional tobacco cigarettes9. This bombardment of the developing brain by big bursts of nicotine leads to addiction. Addiction can lead to lifetime use of these devices and puts young e-cig users at a greater risk of becoming cigarette smokers10. The e-cig companies are using the techniques pioneered by tobacco companies to market their products to adolescents. These techniques include youth themes such as rebellion, glamour, and sex; celebrity endorsements; and sports and music sponsorships; and candy-flavored products11,12. JUUL, who holds the biggest market share of e-cigs, even developed a curriculum for schools and camps to teach kids healthy lifestyles. The company paid for private audiences with children who were told JUULs were “totally safe”13. Electronic cigarettes have been promoted as aids to quit smoking cigarettes, but they have not been proven effective and certainly not safe for this use.

The long term risks of e-cigs are not clear because people have only been using these products for a few years. What we do know is the heated “juice” vapor from these products contains harmful chemicals such as formaldehyde, acrolein, heavy metals, ultrafine particulate, and other cancer causing chemicals. This is contrary to the myth that these devices emit water vapor. Just like cigarettes the long term health risks come from chemicals inhaled other than the nicotine, but the nicotine creates the addiction.

Short term risks have recently emerged. As of 2019 Oct 22, e-cigs have caused 1,604 cases of lung injury with 34 deaths. THC (the psychoactive part of cannabis) and was found in most, but not all, tested samples. Most patients with the illness used both THC-containing products and nicotine-containing products in the 3 months before symptoms developed. Symptoms reported by patients include cough, shortness of breath, or chest pain; nausea, vomiting, abdominal pain, or diarrhea; and fever, chills, or weight loss. These symptoms have developed over a few days to a few weeks.

The emergence of electronic cigarette use over the past decade is a major public health challenge. A comprehensive approach to limiting the damage includes education efforts, cessation efforts, and public policy.


1. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. United States. Public Health Service. Office of the Surgeon General. 1964.

2. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014.

3. Centers for Disease Control and Prevention.Current Cigarette Smoking Among Adults—United States, 2017. Morbidity and Mortality Weekly Report 2018;67(44):1225-32 [accessed 2019 Oct 30].

4. Substance Abuse and Mental Health Services Administration. Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2014 [accessed 2018 Jun 12].

5. Maron, DF. The Fight to Keep Tobacco Sacred. Scientific American March 29, 2018. [accessed 2019 Sep 30).

6. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students — United States, 2011–2014. MMWR 64(14);381-385.

7. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students — United States, 2011–2018. MMWR 68(6);157-164.

8. Fearon IM, et al. Regul Toxicol Pharmacol. 2018;100:25-34.

9. Goniewicz ML, et al. Tob Control. 2018.

10. Miech, R. A., O’Malley, P. M., Johnston, L., & Patrick, M. E. (2016). E-cigarettes and the drug use patterns of adolescents. Nicotine and Tobacco Research, 18(5), 654-659.

11. Legacy. Vaporized: E-cigarettes, advertising, and youth. May 2014. Available at: download/4542/63436/version/1/file/LEG-Vaporized-E-cig_Report-May2014.pd

12. U.S. Department of Health and Human Services (2012). Reports of the Surgeon General. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta (GA), Centers for Disease Control and Prevention (US).

13. Sheila Kaplan. JUUL Targeted Schools and Youth Camps, House Panel on Vaping Claims. The New York Times. July 25, 2019.

14. Centers for Disease Control and Prevention. Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. [accessed 2019 Oct 31].


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