18B.5 Safety and health risks of e-cigarettes

Last updated: December 2016 

Suggested citation: Greenhalgh, EM, & Scollo, MM. InDepth 18B: Electronic cigarettes (e-cigarettes). In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes

Due to the recency of their introduction to the market, there are no controlled studies on the safety of long-term use of e-cigarettes; however, since e-cigarettes do not generate the smoke that is produced by burning tobacco, their use is generally accepted as likely to be less harmful than smoking conventional cigarettes.1-3 Immediate short term adverse effects of exposure to e-cigarettes are usually mild and transient, and may include nausea, vomiting, mouth and airway irritation, chest pain, and palpitations.4   

E-cigarettes deliver nicotine by creating an aerosol of ultrafine particles, but due to the variability and chemical complexity of fine particles and uncertainty regarding the specific components responsible for toxicity, it is unknown whether e-cigarettes have health effects and toxicity similar to the ambient fine particles generated by conventional cigarette smoke or secondhand smoke.5 This uncertainty is further confounded by the lack of regulation and manufacturing standards, leading to potentially harmful and widely varying ingredients, and significant inconsistency between the labelled content and the actual content and concentrations.6 It has become apparent in Australia that some e-cigarettes which are claimed to be free of nicotine, do in fact contain the substance.7 The NSW Ministry of Health tested samples of e-liquids in 2013 and found that 70% of the samples contained high levels of nicotine.8     

A 2016 systematic review of available studies on the health risks of using e-cigarettes concluded that such studies are limited, and findings to date are inconsistent. Limited results suggest use may have the potential to contribute to non-carcinogenic health risks.9  The 2016 US Surgeon General report on e-cigarette use among youth and young adults concludes that: ‘E-cigarettes can expose users to several chemicals, including nicotine, carbonyl compounds, and volatile organic compounds, known to have adverse health effects. The health effects and potentially harmful doses of heated and aerosolized constituents of e-cigarette liquids, including solvents, flavorants, and toxicants, are not completely understood’.10   

18B5.1 Nicotine addiction

Nicotine is among the most addictive of substances known.11,12 While some research suggests that e-cigarettes may be no more addictive than nicotine gum,13 other research has found that in the hands of experienced users, e-cigarettes may deliver systemic nicotine concentrations in a similar range to,14 or even in excess of,15 those delivered by combustible cigarettes.  

Nicotine addiction is discussed further in Chapter 6 - Addiction.

18B.5.2 Nicotine toxicity

The nicotine content of e-cigarettes typically ranges between 0 and 34mg/mL;14 although several studies have reported discrepancies between labelled and measured nicotine content.16,17 At high enough doses, nicotine has acute toxicity.18 Vaping is unlikely to cause nicotine overdose or intoxication, since the amount consumed and absorbed is quite low and comparable to smoking.19-21 However, some e-liquid cartridges contain nicotine doses that are potentially toxic in adults and children if used in ways other than intended.22 In recent years there have been increasing numbers of calls to poison information centres due to unintended ingestion of the e-liquid,23,24 particularly by children,25-27 with a baby in the US28 and a toddler in Israel29 reportedly dying after drinking from an e-cigarette refill bottle. There have also been limited reports of intentional intoxication by injection and ingestion and a small number of suicide attempts associated with the cartridges.30,31 E-cigarettes may also leak, presenting a hazard as nicotine can be absorbed through the skin.32   

For further information, refer to Chapter 6, section 2.

18B.5.3 Nicotine exposure in pregnancy  

Nicotine adversely affects maternal and foetal health during pregnancy, contributing poor outcomes including preterm delivery, still birth, neonatal apnoea, and sudden infant death syndrome.18,25 Nicotine exposure during pregnancy also has lasting adverse consequences for brain and lung development.18 There is currently no clinical knowledge of the efficacy and safety of e-cigarette use in pregnancy, but no amount of nicotine is known to be safe during pregnancy.33 The US Surgeon General noted in 2014 that ‘the evidence is already sufficient to provide appropriately cautious messages to pregnant women and women of reproductive age… about the use of nicotine-containing products such as smokeless tobacco and electronic cigarettes, and newer forms of nicotine-containing tobacco products, as alternatives to smoking.’18 The 2016 report on e-cigarette use concludes that ‘Nicotine can cross the placenta and has known effects on fetal and postnatal development. Therefore, nicotine delivered by e-cigarettes during pregnancy can result in multiple adverse consequences, including sudden infant death syndrome, and could result in altered corpus callosum, deficits in auditory processing, and obesity.’10

18B.5.4 Nicotine exposure in adolescence

There is evidence that adolescents who are exposed to nicotine may become addicted more rapidly, and at lower or more intermittent levels of consumption than adults.34-36 Evidence suggests that nicotine exposure during adolescence, a time during which the brain undergoes rapid development, may have a long-term negative impact on higher cognitive function.18,25 The US Surgeon General ’s 2014 report on the health consequences of smoking noted that ‘the evidence is already sufficient to provide appropriately cautious messages to … adolescents about the use of nicotine-containing products such as smokeless tobacco and electronic cigarettes, and newer forms of nicotine-containing tobacco products, as alternatives to smoking'.18 The 2016 report similarly concludes that ‘nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain’.10      

18B.5.5 E-cigarette use and possible cardiovascular disease risk

Conflicting findings have been reported about the potential health effects of e-cigarette use on the cardiovascular system.37-41 A 2016 review of the evidence regarding the cardiovascular effects of e-cigarettes concluded that the current body of research is limited and short-term, with a lack of high-quality studies and adequate follow-up. Some evidence suggests that e-cigarettes have sympathomimetic effects (i.e., mimicking the action of the sympathetic system) related to nicotine exposure. Limited data suggests that vascular injury may be another concern.42 Another review suggested that, given the non-linear relationship between smoking and cardiovascular mortality (i.e., even light smoking can cause significant cardiovascular health effects), reductions in exposure to certain constituents (such as carbonyls and nicotine) through switching from tobacco to e-cigarettes may not result in proportional harm reduction.43 Overall, existing evidence is limited and further research is needed to establish the cardiovascular risks of using e-cigarettes long-term.

18B.5.6 E-cigarette use and possible cancer risk

The effects of long-term e-cigarette use on cancer risk are unknown. Small amounts of formaldehyde and acetaldehyde, both established carcinogens, have been detected in e-cigarette cartridges.44 In June 2016, the Australian Competition and Consumer Commission commenced action in the Federal court against two online e-cigarette retailers, alleging that their products contained carcinogens and toxic chemicals including formaldehyde, acetaldehyde and acrolein.45 Aerosol produced from some products has also been found to contain traces of carcinogenic nitrosamines, and some toxic metals such as cadmium, nickel and lead. However, the carcinogen levels were nine to 450 times lower than those found in conventional tobacco products.44 A study commissioned by the US Food and Drug Administration in 2009 also detected carcinogens diethylene glycol and nitrosamines at very low levels.46 Some recent studies have suggested that newer products with higher voltage capabilities might produce the same or even higher levels of carcinogenic formaldehyde than tobacco smoke,47,48 but their findings have been challenged.49,50    

In terms of nicotine exposure, the US Surgeon General’s most recent report concluded that there is insufficient data to conclude that nicotine causes or contributes to cancer.18 However, the International Agency for Research on Cancer Advisory Group has recommended that nicotine’s potential as a carcinogen be reassessed as a matter of high priority, because of increased population exposure to nicotine from e-cigarettes, and recent mechanistic data that ‘suggest an association with DNA damage and other pathways of carcinogenesis.’51 Overall, although levels of carcinogens are significantly lower than tobacco cigarettes, regular e-cigarette use over many years is likely to result in some level of harm. Further research is needed to quantify this risk.52

18B.5.7 E-cigarette use and possible respiratory disease risk

Other than nicotine, the main ingredient in e-cigarettes is propylene glycol, which is generally considered to be safe for human consumption if swallowed. However, it has not been tested in the manner that e-cigarette use involves; that is, repeated inhalation over a long period of time.52 Frequent exposure to fine and ultrafine particles, such as tobacco smoke, air pollution, and dusts, can contribute to pulmonary and systemic inflammatory processes and increase the risk of cardiovascular and lung diseases.5 The thresholds for human toxicity of potential toxicants in e-cigarette vapour are so far unknown.5 There have been rare reports of exposure causing irritation to the upper and lower respiratory tract mucosa.53 The level of emissions of compounds such as formaldehyde, acetaldehyde, and acrolein appears to increase with the temperature and age (i.e., number of uses) of the device, and for single-coil vs. double-coil e-cigarettes.54 E-cigarettes have been implicated in individual case reports of exogenous lipoid pneumonia, bronchiolitis, acute eosinophilic pneumonia, pneumonia with bilateral pleural effusions, and inhalation injury and suspected acute hypersensitivity pneumonitis.41 A recent study in mice suggested that chronic inhalation of nicotine-containing e-cigarette liquid could promote the development of obstructive airways disease.55

Researchers have also raised concerns regarding the potential harm of inhaled flavourings used in e-cigarettes on the respiratory system.56-59 They suggest that respiratory toxins in the more than 7,000 unique flavourings might pose a threat to the respiratory health of users, particularly as the flavours have primarily been tested in regard to ingestion, rather than inhalation.57 A 2015 study found that the concentrations of some flavour chemicals in e-cigarette fluids are sufficiently high for inhalation exposure by vaping to be of toxicological concern. The authors suggest that regulatory limits should be considered for levels of some of the more worrisome chemicals as well as for total flavour chemical levels, and that ingredients should be labelled.60     

18B.5.8 Exposure to second-hand vapour

An additional concern regarding the use of e-cigarettes is bystanders’ exposure to second-hand vapour (as exhaled by the user), particularly if the products are used indoors. Several reviews have concluded that e-cigarettes do emit toxicants; however, these emissions are markedly lower than those from conventional cigarettes.61,62 The most recent systematic review has reported that exhaled e-cigarette vapour can contain emissions at a level which affects indoor air quality, including nicotine, particulate matter, glycerine, propylene glycol, formaldehyde, acetaldehyde, polycyclic aromatic hydrocarbons (PAHs) and metals, but mostly to a lesser extent than combustible tobacco products. The authors conclude that while the health impacts of exposure to second-hand vapour are likely to be less than the impact of combustible tobacco, e-cigarettes do have the capacity to produce environmental pollutants, and in sufficient quantities to potentially harm health.  Long term studies on the health effects of exposure to second-hand vapour do not yet exist; nor studies on how vapour might impact on the health of vulnerable populations, including children, pregnant women, and people with chronic lung or heart disease.63

18B.5.9 Explosions and fires

A number of fires have been attributed to e-cigarettes.i These have resulted in several burn injuries, some particularly serious when devices exploded in users’ mouths.64 A man was reportedly killed in late 2014 when a charging e-cigarette exploded and ignited his oxygen equipment.65 Following several fires, in 2015 the International Civil Aviation Organization prohibited airplane passengers and crew from carrying e-cigarettes and other battery-powered portable electronic smoking devices in checked baggage, and from recharging the devices in aircraft cabins.66   

Most of the reported explosions have occurred due to lithium-ion battery failure when the device was charging, largely due to the use of non-approved power adaptors. Although many e-cigarettes have a USB port, plugging an e-cigarette into a USB port or power adapter not supplied by the manufacturer can subject the battery to a higher current than is safe, leading to an explosion and/or fire.64   

18B.5.10 Environmental impact

Little is known so far regarding the environmental impact of e-cigarettes,ii and potential hazards relating to their manufacturing, use and disposal require further investigation. For example, the environmental impact of manufacturing will likely vary based on factory size and the nicotine extracting method used, while disposal of nicotine residue-containing cartridges and battery-containing e-cigarettes represent further potential concerns for the environment.67 There are currently no methods for proper disposal of e-cigarettes or their cartridges.32   


   

 

 

i. Cigarettes are also a major cause of burns (see Section 3.19) and a significant hazard for users of medical oxygen. There have also been reports of other devices with lithium-ion batteries, such as smartphones, exploding due to faulty charging or overheating; thus, this risk is not limited to e-cigarettes.

ii. Cigarette manufacturing also has a substantial environmental impact, and cigarette butt litter remains a major environmental pollutant that poisons waterways and wildlife and causes bushfires (see Section 10.16).  

 

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67. Chang H. Research gaps related to the environmental impacts of electronic cigarettes. Tobacco Control, 2014; 23 (Suppl 2):ii54–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24732165

 

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