Studies highlight risks associated with using e-cigarettes

Two new studies presented at the European Respiratory Society International Congress highlight the risks associated with using e-cigarettes, especially for those who also smoke conventional cigarettes.

One study examined 122 of the most commonly sold e-cigarette liquids in nine European countries and found that all contained at least one substance classified as a health risk.

The other study, a survey of more than 30,000 people in Sweden, found that e-cigarette use was most common among people who already smoke, and that people who use both experience more symptoms, such as a persistent cough, wheezing and coughing up mucus.

The research on the combined effects of smoking and e-cigarettes will be presented by Dr Linnea Hedman, a behavioral scientist at Umeå University in Sweden.

Dr Hedman and her colleagues questioned more than 30,000 people, who were randomly selected from the general population in Sweden, about their smoking habits, use of e-cigarettes and respiratory symptoms.

Around 11% of people surveyed said they only smoke conventional cigarettes, while 0.6% said they only use e-cigarettes and 1.2% said they use both. The results revealed that e-cigarette use was more common among people who currently smoke conventional cigarettes (9.8%), compared to former smokers (1.1%) or non-smokers (0.6%).

The results also showed that people who use both conventional cigarettes and e-cigarettes were the most likely to suffer with respiratory symptoms. Among non-smokers 26% experienced any respiratory symptoms, compared with 34% among those using only e-cigarettes, 46% among those only smoking conventional cigarettes, and 56% among dual users.

Dr Hedman will tell the congress: "Our results show that a proportion of smokers are also using e-cigarettes. It could be that they're turning to e-cigarettes when they're in places like cafes and restaurants where they cannot smoke conventional cigarettes, or it could be that they're using e-cigarettes in the hopes of quitting smoking. One argument for e-cigarettes is that they could help smokers to quit, but our study does not support this argument. If that was the case, e-cigarette use would have been most common among former smokers.

"We have also found that people who use both conventional and e-cigarettes are more likely to suffer wheezing, or a long-standing or productive cough. It could be that some smokers, who are already suffering these symptoms, want to quit smoking by changing to e-cigarettes but they are not managing to stop. Alternatively, it could be that using both products causes worse respiratory effects than either alone. More research is needed to determine whether e-cigarette use contributes to smoking cessation or if it increases the burden of respiratory disease.

"The possible health effects of e-cigarettes are far from established and it will take some years before the long-term effects will be revealed. However, this research adds to the evidence that e-cigarettes cannot yet be marketed as a safe alternative to conventional cigarettes.

The research on the content of e-cigarette refills was presented by Dr Constantine Vardavas (MD, PhD), from the University of Crete.

Dr Vardavas and his colleagues selected a random sample of e-cigarette liquids from the most popular brands on sale in Greece, Spain, Germany, The Netherlands, the UK, Hungary, Romania, Poland and France, which included a variety of different flavours and nicotine strengths.

They analyzed each sample to find out exactly which chemicals were present and in what quantities. Every liquid they tested contained at least one substance that has some level of risk to health according to the United Nations (UN) classification system.

These included methyl cyclopentanolone (found in 26.3% of samples) and a-ionone (found in 8.7% of samples), both which "may cause allergy or asthma symptoms or breathing difficulties if inhaled", according to their classification. Other substances, such as menthol (42.9% of samples), ethyl vanillin (16.5% of samples) and acetyl pyrazine (8.2% of samples), are classified as "able to cause respiratory irritation".

Dr Vardavas told the congress: "The most recent evidence from across the European Union shows a substantial increase in e-cigarette use over the past few years. The EU Tobacco Products Directive notes that e-liquids should not contain ingredients that pose a risk to human health. However, despite growing research on the effect of different ingredients within e-liquids there is little knowledge on the impact they may have on respiratory health.

"Our research reveals that e-cigarette liquids on sale in Europe have ingredients that are potential respiratory irritants. This means that they are substances which irritate the airways according to previous research and international classification standards.

"An EU Directive on e-cigarettes rules that: 'except for nicotine, only ingredients are used in the nicotine-containing liquid that do not pose a risk to human health in heated or unheated form'. We think the respiratory irritants we found may be a breach of this legislation.

"Based on this work, we also think users should be aware that e-cigarettes are not risk-free, and that doctors should inform their patients that e-cigarettes may contain respiratory irritants."

In a separate study also presented at the Congress, Dr Vardavas and his team examined trends in smokers' attempts to quit, with surveys of almost 10,000 Europeans in 2012 and in 2014. They found that use of nicotine replacement therapy declined (from 14.6% in 2012 to 12.2% in 2014) and quitting with the help of healthcare professionals and smoking cessation clinics also fell (6.7% to 5.0%). However, experimentation with e-cigarettes for the purpose of quitting increased (from 3.7% in 2012 to 11.0% in 2014).


  1. Angus MacAskill Angus MacAskill Canada says:

    I don't have access to the studies, but Dr Hedman's statements strike me as being too broad. A cross-sectional survey is inherently limited in what it can tell us about cause and effect. The data presented here would also be consistent with a scenario where the entire population of dual users was using e-cigs to gradually reduce their cigarette intake, on track to quitting completely.

    I don't claim that's the case for ALL dual-users, but it's surely true for SOME of them, and the study design is unable to capture this.

    Moreover, if you're going to make a claim about e-cigs' effectiveness for quitting, you can't just look at former smokers, you need to consider former vapers as well! Otherwise you're ignoring people who used e-cigs to help quit smoking, succeeded, and then quit vaping too.

    • Angus MacAskill Angus MacAskill Canada says:

      As for the question of respiratory problems, did the researchers attempt to control for frequency of smoking, or past smoking? If not, then they are probably seeing the effect of a confounding variable.

      Heavy smokers, long-term smokers, and smokers with trouble breathing are all more likely to try e-cigarettes as a substitute or a quitting aid, but to have trouble quitting completely. The same groups are likely more prone to experience a wheeze or cough, too. Taken together, this could explain why dual-users experience more frequent respiratory problems, but e-cigarettes are not the cause.

      The study author admits this possibility, but assigns it equal likelihood as a novel (and IMO unlikely) interaction between e-cigarettes and regular smoking. She then emphasizes that e-cigarettes "cannot be marketed as a safe alternative" to smoking.

      The author should have done the responsible thing and admitted that the study design does not allow her to make these kinds of statements.

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical.
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