COMMENT: Doubts over e-cigarettes mount in wake of US vaping deaths

A man smoking an e-cigarette in Portland, in the US state of Maine. (AP file photo)

By Dr Tan Kok Kuan

A new medical crisis is gripping the US. Previously healthy young adults are suddenly developing cough, chest pain and difficulty breathing. Many developed respiratory distress, a serious medical condition requiring machines to take over the function of their lungs to keep them alive.

There was one activity linking all these cases some time in the 90 days preceding their symptoms: they had used vapourisers (commonly known as e-cigarettes). The first death from this mysterious vaping-related illness was reported on 23 August from Illinois and by that time, an approximate 200 cases of vaping-related illness were being investigated.

Just over six weeks later as of now, the number of confirmed and probable cases have risen to 1,299 and at least 26 deaths. These numbers are expected to grow.

An e-cigarette is essentially a battery powered electronic device that converts fluid in its tanks into a vapour that can be inhaled.

A study published in the New England Journal of Medicine led by a team of doctors from the Mayo Clinic looked at the findings of 17 cases of vaping-related illness and concluded that the victims were showing signs similar to lung damage caused by inhaling “noxious chemical fumes”. This suggests a mechanism of chemical damage rather than an infection.

Is THC the culprit?

The hunt for the causative chemical proved to be challenging due to the heterogeneity of vaping fluids. Most fingers started to point at THC (tetrahydrocannabinol), a psychoactive constituent of cannabis which users add to their vape pens.

A non-peer reviewed study commissioned by NBC News found that all of the 10 vape fluids they had tested contained THC and myclobutanil, a chemical that becomes hydrogen cyanide when burned.

Vape pens that contain THC also frequently contain Vitamin E, which is added as a thickening agent. Vitamin E has oil-like properties and is known to cause cough, chest tightness and shortness of breath when inhaled.

While it is tempting to blame THC and its related additives solely for the crisis, 16 per cent of patients who suffered from the vaping-related illness were reported to have exclusively used nicotine-containing products.

As yet, there has not been a single chemical commonly identified in all the fatal cases. As investigations continue, researchers are also considering possibilities of confounding factors, such as how the users use their vape pens including how deeply and often they inhale, and that there could be more than one pathology involved.

Regulators relooking at e-cigarettes

All these developments come as a massive setback to the industry as e-cigarettes have been previously lauded as a less harmful alternative to smoking and a means to aid smoking cessation. But scientists and medical professionals have long warned of the unknown long-term effects of vaping.

In 2017 and 2018, there have been isolated reports of severe lung diseases associated with vaping. Are we finally seeing the emergence of the dreaded yet not unexpected long-term health consequences of vaping almost 20 years after Professor Hon Lik from China invented the e-cigarette?

This development has certainly spooked regulators in countries like Malaysia where there are no regulations on the sale and distribution of e-cigarettes. Lawmakers there are now pushing to include e-cigarettes under the Tobacco Law and Smoking Act, which will prohibit their promotion and advertising, and usage in public areas and by minors. Countries that have banned e-cigarettes, including Singapore, Thailand and most recently, India, must be feeling vindicated.

However, proponents of e-cigarettes have been quick to defend the products. The UK has long been a supporter of e-cigarettes where they are actively promoted by the National Health Service as a less harmful alternative to smoking and an aid to smoking cessation. Officials in the UK pointed out that of the almost 4 million active vapers in the UK, there has not been a single reported case of vaping related death.

Public Health England pinned the blame for the recent crisis in the US on “illicit vaping fluids” bought off the streets, especially those containing THC. The Chief Executive of the charity Action on Smoking Health stressed that vapers in the UK should not be scared by what is going on in the US and reiterated that vapers should only source their vape fluids from regulated and legal distributors.

The probe into the crisis is developing rapidly. Hopefully, there will be clearer answers as more evidence is gathered. For now, the US CDC is advising its citizens to refrain from using vaping products, especially those that contain THC.

A key challenge is that regulating and controlling what goes into the fluids in e-cigarettes is near impossible. Many users mix their own fluids at home with components bought off the internet and as such, it is impossible to verify the safety of such mixtures.

Are heated tobacco products the panacea?

The crisis has also turned the spotlight on a lesser known alternative nicotine delivery system known as heated tobacco products. Also powered by batteries, each device heats what looks like a mini cigarette to a temperature high enough to release nicotine but low enough to release fewer toxins compared with conventional cigarettes.

The most common among the products is the iQOS manufactured by Philip Morris International. This system was just approved for sale in the US but has been available in Malaysia from 2018 where it is governed by the same laws that apply to cigarettes.

Heated tobacco products differ from e-cigarettes in two key aspects. First, users are unable to easily tamper with the tobacco stick, which is the source of nicotine. Second, the system uses tobacco, which has been studied extensively.

So even if such a product does not live up to its harm reduction claims, it will be at worst not more harmful than smoking cigarettes. This may very well be the alternative that vapers could turn to if the vaping crisis is not brought under control and result in a blanket ban on e-cigarettes across the world.

Cigarettes continue to be a major preventable health hazard worldwide. In spite of the application of ever harsher rules, laid down in accordance with the WHO Framework Convention on Tobacco Control, smoking rates in many countries including Singapore and Australia have stubbornly refused to drop further.

E-cigarettes were thought to be the panacea but until the mystery of the vaping-related illness is solved and the safety of users can be guaranteed by stringent enforcement, they may turn out to be a case of the antidote being worse than the poison.

Dr Tan has been a practicing physician for the past 20 years. He is currently the Chief Medical Officer of the DTAP Medical Group. His special interests are in the fields of HIV and Tobacco Harm Reduction.

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