Health Consequences of E-Cigarettes [Part 2 of series]
In my first blog in my series on vaping, I described the characteristics of the large, global vaping population. Life insurers care most about the health consequences of e-cigarettes. This segment will touch on several aspects of this concern.
The common thread between conventional smoking and vaping is nicotine. Just like in studies of tobacco smokers, studies of vapers show increased heart rate and blood pressure in proportion to nicotine levels.1 So far research has not found an association between e-cigarette use and cardiovascular disease.2 But given the relatively young population of vapers and short duration of use of this new product, this initial research is not strong evidence of safety.
Long-Term Health Effects of Vaping
Because the e-cigarette product is so new, direct observation of long-term health outcomes does not exist. Examination of surrogate evidence provides a way to address the problem: One form of surrogate evidence examines clinical effects that can develop more quickly than mortality. When smokers with asthma switch to e-cigarettes, lung function and respiratory symptoms improve. Smokers with COPD who switch have fewer exacerbations. However, animal and in vitro studies suggest adverse effects in the respiratory system result from e-cigarette exposure.3 Moreover, in both healthy human volunteers and patients with asthma or COPD, vaping for 10 minutes triggers significant airway obstruction.4
Cancer risk accumulates slowly, and it is too soon to obtain direct evidence. Heating the vaping solution produces a chemical mix that is far simpler than tobacco smoke. Still, it generates formaldehyde and other molecules that are potentially risky. E-cigarette aerosols can create DNA damage in laboratory models. The level of exposure may or may not reach a level to induce cancer.
More is known about the health effects of some of the typical constituents in the vaping aerosol itself. To maintain moisture, e-cigarette compounds commonly contain propylene glycol or glycerine. The European Commission does not classify propylene glycol as hazardous, even though studies have shown that it may induce respiratory symptoms and release of inflammatory mediators. Extensive vaping can create exposure close to the level of occupational exposure limits for propylene glycol.5
Flavoring is extremely variable with thousands of unique e-liquid varieties. Some of them are generally regarded as safe for ingestion. Inhalation may or may not exhibit similar effects. Others have a potential respiratory health hazard. The biggest unknown, however, relates to impurities and undocumented ingredients that may exist in the products of innumerable suppliers around the world.
Assessing Risk of Lung Injury
The importance of specific ingredients became obvious with the discovery of e-cigarette, or vaping, product use-associated lung injury (EVALI). As of February 2020, the CDC reported 2,807 hospitalizations and 68 deaths in the U.S. The outbreak peaked in September 2019.6
In 2020 so far, the CDC reports that the incidence rate is <10 cases/week, and 82% of cases reported use of THC-containing products. Among those, 78% obtained their inhalant from informal non-commercial sources (friends, dealers, or online). Many THC products add Vitamin E to the solution as a diluent. Vitamin E is an oil and EVALI resembles a condition called lipoid pneumonia that develops from deposition of fats or oils in the lung. It is obvious that any assessment of the effects of vaping must separate these products from the commercial manufactured offerings of nicotine and flavorants.
Right now, research tentatively shows that vaping poses lower health risk than smoking tobacco.
In my next blog, I will examine estimates of harm and consider the implications if insurers wish to differentiate the risk of vaping from smoking and nonsmoking. In the meantime, if I can help you think through this medical underwriting issue for your company, feel free to reach out.
- U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. 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, 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf.
- Osei AD, Mirbolouk M, Orimoloye OA, et al. Association between e-cigarette use and cardiovascular disease among never and current combustible-cigarette smokers [published online ahead of print March 8, 2019]. Am J Med. https://doi.org/10.1016/j.amjmed.2019.02.016.
- H-W Lee, et al. E-cigarette smoke damages DNA and reduces repair activity in mouse lung, heart, and bladder as well as in human lung and bladder cells. PNAS February 13, 2018 115 (7) E1560-E1569; first published January 29, 2018. https://doi.org/10.1073/pnas.1718185115.
- Pisinger C, Dossing M. A systematic review of health effects of electronic cigarettes. Prev Med 2014;69:248-260. https://doi.org/10.1016/j.ypmed.2014.10.009.
- Behrakis, Panagiotis & Vardavas, Constantine. (2016). PRECISE (Potential Risks from Electronic Cigarettes & their technical Specifications in Europe) Project. doi:10.2818/422906.
- https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-information, accessed May 14, 2020.