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E - Cigarettes: The risks

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  • E - Cigarettes: The risks

    The potential danger to small children from these devices is enormous:

    Years of antitobacco campaigning and public health legislation have resulted in a new market for smokeless nicotine products. The main delivery device is known as the electronic (e-) cigarette. The basic premise is that a heat source is applied to liquid nicotine, atomizing or vaporizing it. This allows the user to inhale it and provides a sensation similar to that of smoking.

    Proponents of this technology promote it as a healthy alternative to smoking. They evidence this by citing a reduction in chemicals and carcinogens. The truth is that there are some preliminary data that suggest even using e-cigarettes may have detrimental effects in the lungs. We simply don't have the long-term data to know for sure whether any benefit exists from switching from cigarettes to e-cigarettes.

    Certainly there is some logic that says: If e-cigarettes can be used as a bridge to not only smoking cessation but nicotine cessation, the long-term benefits may outweigh the short-term risks. The reality is that that's not always the norm. Many people end up trying e-cigarettes and trading one addiction for another, and they never completely wean off nicotine altogether. Additionally, this unregulated market has opened up a whole new generation to nicotine products that might not have otherwise tried tobacco.

    What has this led to? This has led to the ubiquitous availability of highly concentrated nicotine products, exposure to which can result in severe toxicity. To understand nicotine toxicity, we have to know nicotine. Nicotine is a potent, plant-derived parasympathomimetic alkaloid. I know: a mouthful. Essentially, it's an agonist of the nicotinic acetylcholine receptor.

    At low doses, this results in stimulation of the reticular activating system as well as dopamine release. As the dose increases, we start to see cardiovascular effects, things like hypertension or tachycardia. Seizures are a mainstay of central nervous system toxicity. As we get into supertherapeutic and toxic dosing, we can start to see loss of receptor specificity, so we can get presentations that are more similar to the classic cholinergic toxidrome and include bronchorrhea, excessive secretions, and profound gastrointestinal disturbance. At very high or extreme doses, nicotine can result in neuromuscular blockade, analogous to organic phosphate poisoning or even nerve agent exposure, which leads to respiratory failure and even death.

    Why are we talking about this now? Hasn't this been around for a long time? Of course, the answer is yes. Historically in kids, nicotine toxicity has come in the form of exploratory ingestions with tobacco. Traditionally, there has actually been sort of a protective mechanism or rate-limiting step built in. In other words, tobacco is so noxious to the gastrointestinal system that it is, quite frankly, hard for a child who is actively becoming nauseous and vomiting to ingest enough to be severely toxic.

    Of note, if a child were to consume a first-generation e-cigarette that had a self-contained small liquid nicotine cartridge, it would often pass through their gastrointestinal tract completely and be eliminated before they were ever able to release enough nicotine to become severely toxic.

    Where are we today? In the spring of 2014, the US Food and Drug Administration only regulates therapeutic nicotine products. Unfortunately, there's no regulation of the recreational nicotine market, which includes brand or trade names that you may recognize, like Nicorette« gum or Nicotrol« inhalers. Why is this a problem? There is no incentive to implement costly consumer protection. For example, we don't see consumer warning labels on any of these products discussing the risks associated with nicotine use or any other ingredients that might be included in the product. There's certainly no child-protective packaging on any of these products.

    Finally, there is no quality control. There are no guarantees that the consumer is actually getting what they think they're getting. To boot, the manufacturers are placing very attractive and appealing cartoon-like labels on these products or adding sweet-smelling or pleasant-tasting flavors like lemonade. What do we get? These essentially become child magnets. It is no surprise that the number of nicotine exposures in children reported to the National Poison Data System in fact tripled from last year to this year.[1]

    We know exposures are up, but why is this so toxic? The primary reason is the high concentrations. These products are marketed in 1.8%, 2.4%, or even 10% solutions. In terms of nicotine content, these are orders of magnitude higher than traditional tobacco products.

    The best way to demonstrate the seriousness and highlight the lethality of this is to demonstrate how a small volume can be dangerous. We know that the lethal dose, 50% or LD50, of nicotine is between 1 and 10 mg/kg. In a volume like this -- this is a 1.8% solution sample that I picked up at my local vape shop -- that is 18 mg/mL of nicotine. For the sake of easy math, let's round that to 20 mg/mL. We know that the potential lethal dose is 10 mg/kg. In a solution like this, approximately 20 mg/mL, a dose of 0.5 mL/kg could be lethal. A small 15-mL vial like this -- simply 1 tablespoon -- could be lethal to a 30-kg (65-lb) child.

    When I show parents that this alarmingly small volume could be deadly to their child, they say, "I had no idea how dangerous this is." It's true. Liquid concentrated nicotine easily has the potential to be the most deadly substance in your house.

    Robert A. Bassett, DO
    Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

    "You're just a jaded cynical mother****er...." Jeffpeg

    (more comments in my User Profile)

  • #2
    The addictive qualities of e cigarettes vs real cigarettes:

    (Reuters) - The nicotine formula used by controversial e-cigarette maker Juul Labs Inc is nearly identical to the flavor and addictive profile of Altria Group Inc's highly successful Marlboro cigarette brand, new research suggests.

    A study released on Tuesday from researchers at Portland State University in Oregon helps to explain why a growing number of young people who never smoked cigarettes have become regular users of Juul vaping devices.

    The formulation of Juul's nicotine aerosol was designed to make it far easier for users to inhale larger quantities of nicotine without gagging, gasping or coughing - or even noticing.

    "It becomes obvious why novice users, people who've never smoked before, find it easy to try Juul," said David Peyton, a professor of chemistry at Portland State University who worked on the study, published in the journal Tobacco Control. "And once you try it, you're getting dosed with a high concentration of nicotine."

    Directly comparing Juul vaping devices to Marlboro cigarettes, the researchers analyzed the amount and chemical makeup of the nicotine in Juul's cartridge-like disposable "pods."

    In addition to sweet flavors and its sleek, flash drive-like design, Juul is notable for popularizing what are known as "nicotine salts," a smoother form of nicotine than what was contained in earlier e-cigarettes, according to Juul's own patents and outside research on their formula.

    By adding organic acids to liquid nicotine, San Francisco-based Juul was able to reduce the amount of "freebase nicotine" in the aerosol that users inhale.

    Freebase nicotine, common in e-cigarette liquid prior to Juul's arrival in 2015, is harsh and difficult to inhale at high concentrations. Juul virtually eliminated the harsh side effects.

    While e-cigarettes have been marketed as a means to help smokers quit or cut down, public health officials have expressed concern that they are drawing a new, younger generation into nicotine addiction. Juul has come under intense scrutiny from regulators, lawmakers and attorneys general over the surging popularity of its products among teenagers in recent years.

    A recent study found that nearly 60% of high schoolers and 54% of middle schoolers who use nicotine vaping products said Juul was their usual brand.

    Peyton and fellow researchers James Pankow and Anna Duell measured the amounts of nicotine in Juul and how much of that nicotine was in the harsher freebase form of the chemical.

    They determined that Juul's potency and flavor profile was almost exactly the same as Marlboro cigarettes, describing Juul as an "e-cigarette analogue" of the U.S. market-leading brand.

    "Juul is all the things about Marlboro that are addictive," said Pankow, an expert in the chemistry of nicotine and tobacco smoke. "Then they take away the bad smell and add some flavors. It's a much more pleasant experience."

    Under pressure from regulators and lawmakers, Juul in recent months stopped selling flavors other than menthol and tobacco in the United States, but continues to sell fruit and dessert flavors in other countries.

    A study released last month by researchers at Pennsylvania State University found that Juul delivered more nicotine to the bloodstream, and at a faster rate, than earlier e-cigarettes, and that its nicotine boost was similar to that of a cigarette.

    Juul Labs did not immediately respond to a request for comment on the new study's findings.

    In an earlier statement, the company said its products were designed to get adult smokers to switch from cigarettes. Therefore the company "sought to create a nicotine-based e-liquid that mimicked the nicotine experience" in cigarettes, according to the statement.

    "Providing a similar nicotine experience was a priority given the fact that early generation e-cigarettes had failed in this respect and, as a result, did not convert a significant number of adult smokers from cigarettes," the company said.

    Juul cited studies it commissioned showing that between 30% to 50% of adult smokers who use Juul "switch completely from smoking cigarettes within six months."

    A separate U.S. study released on Monday found that e-cigarette use significantly increases the risk of developing chronic lung conditions such as asthma or emphysema.

    The Portland State researchers noted that Juul had rapidly duplicated - and improved - a formula that tobacco growers and purveyors took centuries to perfect: A way to deliver potent amounts of nicotine through inhalation.

    The tobacco industry for centuries tinkered with the chemistry of nicotine in tobacco through various drying techniques and additives, aiming to make burned tobacco smoother to inhale, the researchers noted.

    They said Juul's evolution from earlier e-cigarettes was reminiscent of the tobacco industry's cigarette development.

    Juul has "essentially duplicated the world's most popular cigarettes, which means this should be attractive to cigarette users," Peyton said. "This is probably also a good way to get the curious novice who has never smoked.

    "It's difficult to go for the one population without hitting the second."

    SOURCE: Tobacco Control, online December 17, 2019
    Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

    "You're just a jaded cynical mother****er...." Jeffpeg

    (more comments in my User Profile)


    • #3
      The dangers associated with e cigarettes has changed significantly since their introduction in 2013:

      In July 2013, a group of 12 experts in decision science, medicine, pharmacology, psychology, public health policy, and toxicology rated the relative harm of 12 nicotine-containing products by using 14 criteria addressing harms to self and others. The group concluded that combustible cigarettes were the most harmful and that electronic nicotine delivery systems (electronic cigarettes or e-cigarettes) were substantially less harmful than combustible cigarettes. These results have been characterized and repeated in the popular media as e-cigarettes are "95% less risky" or "95% less harmful" than combustible cigarettes. However, as the authors noted in a sweeping statement regarding the shortcomings of their own work, "A limitation of this study is the lack of hard evidence for the harms of most products on most of the criteria."

      Despite this lack of hard evidence, Public Health England and the Royal College of Physicians endorsed and publicized the "95% less harmful" assertion. Senior Public Health England staff emphasized the "evidence" underlying the 95% figure, despite the evidence being lacking. Much has been written about the dubious validity of the "95% less harmful" estimate in 2014 to 2016, especially about the paucity of research on the health effects of e-cigarettes available in 2013. After six years of e-cigarette–focused research, which has yielded a growing body of hard evidence regarding harm, the time has come to re-examine that estimate.

      There is ample evidence that the range of e-cigarette products available today is very different from that in July 2013. The differences are such that, even if the 2013 estimate was valid then, it can no longer apply today. For example, in addition to using different materials and more numerous heating coils, many e-cigarettes today can attain power output that exceeds that of most over-the-counter 2013 models by 10 to 20 times (i.e., up to and sometimes exceeding 200 watts). Greater power increases the potential harms of e-cigarette use because more aerosol is produced that exposes users to increased levels of nicotine and other toxicants. It also increases bystander exposure to any harmful aerosol constituents because users exhale more aerosol. In addition, greater power increases the potential for malfunction (e.g., the device exploding), which could harm users and bystanders.

      Also, e-cigarette liquids have changed considerably from 2013, with widespread availability of thousands of flavors that use chemicals "generally recognized as safe" to eat but with unknown pulmonary toxicity. Perhaps the most striking change has been the pervasive marketing of liquids with protonated nicotine. Protonated nicotine ("nicotine salt") is made by adding an acid to free-base nicotine, thus introducing another potential toxicant that was rare in 2013. Relative to free-base nicotine, aerosolized protonated liquid is less aversive to inhale, allowing users to increase the nicotine concentration of the liquid and likely increase their own nicotine dependence. Protonated nicotine e-cigarette liquids are available today in concentrations greater than 60 milligrams per milliliter, and these liquids have become very popular, sparking a "nicotine arms race."

      There is ample evidence, unavailable in 2013, that e-cigarette aerosols contain toxicants and that these aerosols are harmful to living cells in vitro and in vivo. For example, thermal degradation of e-cigarette liquid constituents can produce volatile aldehydes, which, at concentrations generated by e-cigarettes, display a variety of cardiorespiratory toxic effects. E-cigarettes can produce carcinogenic furans in addition to other toxicants such as chloropropanols. Even at room temperature, e-cigarette liquids can be unstable, producing irritating acetal compounds carried over into the aerosol. Numerous studies demonstrate that cell function is compromised following exposure to e-cigarette aerosol. Similarly, animals that are exposed to e-cigarette aerosols show clear indication of adverse consequences, including in models related to cardiovascular disease.

      Recent evidence reveals that e-cigarette users show evidence of harm. For example, in a sample of healthy young occasional cigarette smokers who used an e-cigarette with or without nicotine, airway epithelial injury was observed in both conditions, with the authors concluding, "Thus, [e-cigarette] aerosol constituents could injure the respiratory system or worsen preexisting lung disease through a variety of mechanisms." Consistent with this report, wheezing, a symptom of potential respiratory disease, has been associated with e-cigarette use. E-cigarette use increases heart rate, blood pressure, and platelet activation, and decreases flow-mediated dilation and heart rate variability, effects that are prognostic of long-term cardiovascular risk. Indeed, a preliminary report indicates that e-cigarette users may be at increased risk for myocardial infarction and coronary artery disease.

      Since 2013, numerous surveys have demonstrated that e-cigarette use is increasing among individuals who previously were na´ve to nicotine and that these individuals are at increased risk for initiation of combustible cigarette smoking. As the US National Academies of Sciences, Engineering, and Medicine concluded, "There is substantial evidence that [e-cigarette] use increases risk of ever using combustible tobacco cigarettes among youth and young adults."To the extent that initial e-cigarette use is a causal factor in subsequent combustible tobacco smoking for an individual who would have otherwise never initiated smoking, e-cigarette use could be considered to be as harmful as tobacco smoking for that individual.

      Differences in toxicant content between e-cigarette aerosol and cigarette smoke, by themselves, cannot convey lesser lethality because toxicity depends upon both the extent and mode of use. For example, propylene glycol (PG) is one of the primary constituents of e-cigarette aerosol and is generally recognized as safe when eaten but, when injected intravenously over a period of days, is toxic. E-cigarette aerosols containing propylene glycol and vegetable glycerin, another common constituent, cause inflammation in human lungs, suggesting differing safety profiles for inhaled versus ingested propylene glycol and vegetable glycerin. Furthermore, as the toxicants in e-cigarette aerosol sometimes differ from cigarette smoke, so might any resulting e-cigarette–caused disease states. There is little doubt that exclusive e-cigarette users are unlikely to die from lung cancer that is caused by carcinogenic tobacco-specific nitrosamines or polycyclic aromatic hydrocarbons, toxicants largely absent from e-cigarette aerosols. What diseases they may die of—and if their deaths are hastened by their e-cigarette use—will be part of the much-needed evidence base upon which valid risk estimates can be built.

      In sum, a 2013 evidence-lacking estimate of the harm of e-cigarettes relative to combustible cigarettes has been cited often. However, since 2013, e-cigarette devices and liquids have changed. Evidence of potential harm has accumulated. Therefore, the evidence-lacking estimate derived in 2013 cannot be valid today and should not be relied upon further. Future estimates of the harm of e-cigarettes should be based on the evidence that is now available and revised accordingly as more evidence accrues.
      Experienced Community organizer. Yeah, let's choose him to run the free world. It will be historic. What could possibly go wrong...

      "You're just a jaded cynical mother****er...." Jeffpeg

      (more comments in my User Profile)


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