Introduction
There is a common claim that vaping is safer than traditional cigarettes – particularly as it does not contain tar or carbon monoxide as traditional cigarettes usually do. It is on this basis that many vape industry players and associations have been vocal against the regulation of vape products akin to cigarettes, claiming it is unreasonable to equate vaping to smoking cigarettes. However, vaping is far from a safe alternative to smoking and can bring similar health implications.
Thus, this article serves to explore the health implications of vaping. Evaluating the literature available by both opponents and proponents of vaping, the paper begins by breaking down the components of vape products before discussing the health effects of vaping.
This Views article is the first installation of a three-part series discussing the issues surrounding the consumption and regulation of vape products in Malaysia.
Components of vape products
Vape products are made of three main components; vape devices, pods (also known as cartridges or tanks), and liquids (also known as vape juice). Devices are usually battery-operated and are used to convert the liquid into aerosol to be inhaled. There are two types of vape devices, namely the open system and the closed system. Open systems have a clearomiser (tank), which is then filled manually with vape liquids, while the closed system uses a pre-filled cartridge.
Meanwhile, the pod or tank is the component that houses vape liquids and can either be pre-filled (closed system) or refillable (open system). Vape liquids can also come in a variety of flavours, and are the most popular component manufactured and sold, with 96% of manufacturing and 61% of sales being vape liquids. There are generally two categories of vape products: those which contain nicotine and those without.
Chemical components of vape liquids
The nicotine found in vape products are added either of these two forms: freebase nicotine (which originated back in the 1960s) and nicotine salt (which has appeared in more recent years). Freebase nicotine is considered the purest form of nicotine and is created by adding ammonia to pure nicotine compounds to allow nicotine to be absorbed by the body. Meanwhile, nicotine salts are made from the nicotine extracted from tobacco leaves and thus are naturally occurring. Despite both being a form of nicotine, the type of nicotine added can influence the rate of nicotine absorption and ‘vaping experience’.
Aside from nicotine, vape liquids contain three other main components: solvents, sweeteners, and flavours. Solvents are used to dissolve nicotine, thus allowing it to be inhaled. The most used solvents are propylene glycol or vegetable glycerine (or a mixture of both) and are largely odourless and colourless. Vegetable glycerine also aids in the formation of vape clouds (the puff usually associated with vaping) and is naturally sweet, which may enhance vape juice flavours. Alone, vegetable glycerine or propylene glycol does not offer many flavours and is generally tasteless.
To achieve the variation of flavours and scents that vape products are known for, artificial sweeteners such as sucralose and ethyl maltol, as well as artificial flavouring, are added. However, the chemical components used to derive these flavours are largely undisclosed and the ingredient list of what is inside the vape liquids is unavailable on either the packaging or in the description of their online shops or e-commerce platforms. Additionally, even if those ingredients are recognized as “food safe” this is only in reference to when they are consumed as food and may take on different properties when heated into aerosol – some potentially toxic.
The health risks of vaping
Harms of nicotine and nicotine addiction
Nicotine is highly addictive and potentially lethal at a dose of 6.5-13 mg/kg when taken orally (around 0.5-1 g for the average person). Even in non-toxic doses, nicotine has been found to increase blood pressure, increase heart rate, narrow arteries, and contribute to the hardening of artery walls. All these risks combined can eventually lead to a heart attack, stroke, and other life-threatening complications. As nicotine can stay within the body system for around 6-8 hours, continued ingestion of nicotine can lead to its accumulation, risking nicotine overdose.
Aside from cardiovascular concerns, nicotine has been identified as one of the major components responsible for gastrointestinal disorders, contributing to inflammation in both the stomach and colon. Nicotine and nicotine-derived nitrosamine are also risk factors for gastrointestinal cancer.
Additionally, nicotine has also been shown to lead to decreased immune response as well as ill impacts on reproductive health, cell proliferation, oxidative stress, as well as apoptosis. Furthermore, nicotine increases the risk of DNA mutation through various mechanisms which can lead to cancer as well as resistance to chemo and radio therapeutic treatments.
There are also potential risks brought on by nicotine to the foetus from vaping during pregnancy and lactation. Nicotine has been shown to affect foetal brain and lung development, reduction in offspring weight, as well as exacerbate the development of allergic asthma in the child. This is particularly concerning as some women view vaping as being less harmful, despite e-cigarettes carrying the same risks to the foetus as traditional cigarettes.
In terms of nicotine addiction, the more nicotine present in a product, the more addictive it is. This is particularly a concern as an EC liquid in Malaysia could have up to 50 mg of nicotine per 1 ml (5% nicotine) compared to the maximum concentration of 20 mg per ml (2%) nicotine in Indonesia, United Kingdom, and Europe – though Malaysia is expected to follow suit by October 2025 with the same standard. However, it should be noted that there is no global consensus on what constitutes a ‘safe’ dosage as consumption of nicotine will always carry risks, though it varies by the person’s size, weight, age, and height. Additionally, nicotine withdrawal symptoms due to nicotine addiction is also another concern when it comes to nicotine consumption as it makes it much harder for one to quit, either smoking or vaping.
Increased risks of cardiovascular diseases
Vape users, especially daily users, are more likely to have a heart attack and coronary artery disease compared to those who do not use vape or cigarettes. A study by the American College of Cardiology found that vape users were 56% more likely to have a heart attack, 44% more likely to have coronary artery disease, and 10% more likely to have circulatory problems such as blood clots when compared to those who do not vape. Even when controlled for other cardiovascular risk factors such as age, sex, body mass index, cholesterol, blood pressure, and tobacco cigarette smokers, the association was still significant at 34% more likely to have a heart attack and 25% more likely to have a coronary artery disease.
Vape products have been shown to raise blood pressure and heart rate, decrease the elasticity of artery walls, as well as inhibit the function and damage the lining of blood vessels – all of which increases the risk of heart attacks. While nicotine (both in traditional cigarettes and vape products) itself is a component that leads to an increase in cardiovascular disorders, nonnicotine vape liquids can also lead to blood vessel damage due to other irritants found in its vapours.
Particularly concerning is that the risk of cardiovascular diseases has been increasing among youth, and around one fifth of heart attack patients are those younger than 40 years old. In Malaysia’s case, a study on the risks of coronary artery disease among youth aged 15-24 found that 70% of the participants has at least one cardiovascular risk factor. While heart disease is usually the result of a combination of risk factors, smoking (either by traditional or electronic cigarettes) is still a prominent risk factor.
Health risks identified from chemicals found in vape products
Unlike traditional cigarette, where the health risks from its various chemical components have been mostly identified, research on the adverse health effects of vaping is still ongoing. However, early findings have indicated that the harms of vape products may be underplayed as harmful compounds are not only limited to the components of the vape liquid, but also the formation of new molecules from chemical reactions when the liquid is heated.
Aside from the liquid itself, the metal coils which heat the vape liquid to produce aerosol can also lead to contamination. These coils can be composed of various metals such as alloy of iron-chromium-aluminium (kanthal) or a combination of nickel and chromium, thus leading to dangerous levels of exposure and inhalation of toxic metals and metals that are toxic when inhaled. The existence of lead is particularly a concern as studies have reported it as a major neurotoxicant which increases the risk of cardiovascular and kidney diseases, even at low levels of exposure. Meanwhile, chromium and nickel have been established as inhalation carcinogens.
E-cigarette- or vaping-use associated lung injury (EVALI)
E-cigarette- or vaping-use-associated lung injury (EVALI) is another growing health concern arising from the use of EC and vape. EVALI is a serious inflammatory condition that damages the lungs due to the inhalation of tiny particles of liquid nicotine and flavouring.
After an outbreak of lung injuries and deaths associated with modified vape products, the United States Centres for Disease Control and Prevention (CDC) has identified vitamin E acetate as a chemical of concern. While the commercial sale of vape products containing vitamin E acetate has been phased out since its association to “popcorn lung”, it should be highlighted that some manufacturing of counterfeit vape liquids are widespread and are likely to contain poorer quality compounds.
The danger of underplaying vaping risks
While not declared as safe, there is a general perception that ECs or vape products are a harm-reducing alternative to traditional cigarettes, but how much of this holds true? Traditional cigarettes have been found to contain more than 4,000 toxic substances, which include, but are not limited to, acrolein, carbon monoxide, acetaldehyde, and cyanide - some of which are associated with increased risks of cancer. However, the risks of various other substances in vaping liquids are under-studied and may bring similar harms.
There are also several arguments being made of vaping being a gateway to traditional cigarette smoking. Opponents of vaping argue that aside from the health risk of ECs itself, there has been a rising number of never-smoker youth who have started vaping, and this introduction to nicotine has often led to the uptake of traditional tobacco products later.
When it comes to the risk of cardiovascular diseases, vaping can be as dangerous as smoking due to its nicotine content. While the dangers of smoking cigarettes have long been associated with lung cancer, the incidence of cardiovascular diseases among smokers is a pressing issue. It is estimated that 10-20% of cigarette smokers will have lung cancer. However, when compared to other health risks, around 24.6% of young (aged 20-39 years) men and 19.9% of women who smoke will experience their first incident of a cardiovascular disease. Young smokers are also twice more likely to die due to a cardiovascular disease compared to non-smokers across both genders. Thus, narratives surrounding the dangers of vaping should reflect this reality.
Conclusion: Combatting health misinformation on vape products
Smoking is extremely harmful, regardless of the method. While studies on the health effects of vaping have been increasing in the past years, it seems the vape industry is expanding at a faster rate.
Advocates of vape products have greatly highlighted vaping as a safer alternative to smoking, with some vape companies even have slogans promoting vaping in place of smoking. However, various studies have pointed that health risks of vaping are akin to that of traditional cigarette smoking when its effects on lung and cardiovascular function are compared as well as the risks of nicotine poisoning and addiction. Furthermore, limited research on the various other chemicals found in vape liquids, as well as emerging and rising cases of EVALI, may imply that continued use of vape devices can lead to other future health concerns and discoveries.
Claims of vaping being less harmful than smoking are reminiscent of the claims made in the 1940s on filtered and low-yield cigarettes being promoted as reducing the risk of smoking, a claim which has since been debunked. To combat this misinformation rampant in the 1940s-1950s, the United States Federal States Commission (FTC) banned and took several legal actions against health or medical claims made by tobacco companies. Hence, the claim of vaping being less harmful than cigarettes or vaping should be evaluated with the same scepticism as more studies point out otherwise.
