Vaping- the beginnings of a disease description
It seems that the tobacco industry has won the first major vaping battle. They have succeeded in getting their new product legal, and now they do not have to prove it is safe, the medical world has to prove it unsafe. Progressive elements of the medical profession are describing the diseases caused by vaping. Its progressive practitioners are also aware of the political aspects of vaping’s progress, though their power in this area is not great.
After my last article on vaping Anne Jones, who used to run ASH (Action on Smoking and Health,) sent me a significant lecture by Prof Andy Bush, from the Brompton Hospital. (Brompton is probably the most prestigious hospital for respiratory diseases in Britain).
The 45 minute lecture is quite medical/technical and as such quite hard going, but it is interesting in that it combines very detailed medical aspects with an astute analysis of the political and economic significance of vaping. As a student I was subjected to endless lectures on the harm of tobacco without any consideration of the political aspects of its political cause or prevention. As Prof Bush himself says, ‘Fool me once, shame on you. Fool me twice, shame on me’.
He points out the similarities between smoking and vaping, but also the differences. There is something of a nightmare of acronyms, so I will help where I can.
Currently vaping is being marketed using the same symbols of success as was used before tobacco had any restrictions on it, freedom, rebellion and glamour. The difference is that it now uses social media to market to CYPs (Children and Young People). BAT has spent a Billion pounds on social influencers. Although vaping is supposedly allowed to help people get off tobacco, the marketing to kids is to those who do not smoke anyway, so clearly it either a gateway drug to smoking or an entirely separate habit to be fostered and developed.
He points out that the tobacco industry has taken over the major vaping brands. VUSE is owned by RJR, who were R.J.Reynolds Tobacco. VYPE is owned by BAT, British-American Tobacco. BLU is now owned by Imperial Tobacco, and JUUL is now significantly owned by Altria, the new name for Philip Morris.
If that were not enough, one brand Puffit2 is owned by a company called Discreet Vape Company and the vaping device looks like a Ventolin inhaler! Philip Morris purchased Vectura, a British pharmaceutical company that manufactures respiratory drug delivery devices, in September 2021.
ENDS (Electronic Nicotine Delivery Systems) (= vaping devices) deliver chemicals. Prof Bush points out these chemicals have no information publicly available about their nature and properties. 18 flavours have carcinogenic, tobacco-specific components and there are bacterial and fungal contaminants in a high percentage of vaping products. These contaminants may have their own ability to generate allergic lung diseases, which are similar to emphysema. In one case the nicotine was at 120% of the level stated on the pack.
Passive vaping is similar to passive smoking in that the non-vapers get similar levels of nicotine in their urine to passive smokers.
Vaping is not a gateway to smoking cessation and may even be a gateway to smoking. A study which compared nicotine replacement therapy to vaping showed that while 9% of nicotine replacement patients were off cigarettes after 6 months as opposed to 18% of people using vaping, 80% of the people who had used vaping were still vaping a year later (Hajek et al, NEJM 2019). If Buprion was used with nicotine replacement the quit rate was 25% at 6 months and 20% in a year. Varenicycline achieved 27% (Borelli and O’Connor NEJM 2019). Interestingly, if you pay people to quit, it is a better investment than the drugs!
Vaping has risen rapidly amongst American teens and is currently at 28% and the prevalence of smoking has stopped declining since the vaping rise started.
Prof Bush’s lecture states that the acute toxicity of vaping is actually worse than cigarettes. Researchers always do an immense amount of work, and doctors struggle to keep abreast of it. The effect has been measured on foetal lungs, levels of all kinds of proteins, cytokines, chemokines, enzymes, Cell functions, lung pathology, oxygenation levels and from many areas including broncho-alveolar lavage (BAL), (i.e. washing from lungs). Rat models have also been used to look at emphysema (poor little guys). It increases their alveolar (lung air sac) size and causes a fall in transcutaneous oxygen levels. This may be due to a lipoid pneumonia due to lipid (fats) being leached out of the lungs. The negative effects of e-cigarette vapour condensate on macrophages (the cells that fight infection) were similar with or without nicotine in the condensate. The condensate was also more toxic than the e-Cigarette liquid! (Scott, Thorax 2018).
Vaping has been shown to increase bacterial adherence to epithelial cells which increases susceptibility to infection. It also considerably worsens the effect of COVID infection.
There are case histories of a 16 year old previously healthy boy who was admitted urgently to an Emergency Dept with a lung disease so serious that he ended up on ECMO (Extra-Corporeal Membrane Oxygen- the artificial lung). He had only used OTC (Over the Counter) vaping products.
Prof Bush describes a new disease that has been called EVADI (E-cigarette Vaping Acute Lung Injury), though it would not be medicine if they were not arguing over the new name which some want to call EVALD (E-cigarette Vaping Acute Lung Disease).
Bush finally asks that the recommendations of FIRS, (Forum of International Respiratory Societies) be implemented:
- ENDS (Electronic Nicotine Delivery Systems) should be considered as tobacco products and taxed and regulated as such.
- Sales to CYPs (Children and Young People = minors) must be prohibited and this must be enforced.
- All advertising and promotion should be regulated and made inaccessible to CYPs.
- Flavourings increase rates of youth initiation, so should be banned in ENDS
- Vaping should be prohibited in indoor locations, public parks, and places where children and youths are present.
- While their health risks are increasingly recognised, more research is needed
- Routine surveillance and surveys concerning combustible and electronic cigarette use should be carried out.
Prof Bush makes the point that they also need plain packaging and health warnings like tobacco products and says, ‘There is no chemical model that shows inhaling hot chemicals is a good idea. You show me the proof that it is harmless.’
We all need to lobby on this. Here is the video of the lecture: https://www.youtube.com/watch?app=desktop&v=yhdiIuz0ec4&fbclid=IwAR2ETBxTR8LD87Nmng54uo_w2xZ6vI7kRmYBqITPOv36R0