Puff the magic dragon: the myth of ‘safe’ e-cigarettes

E-cigarettes are often pushed as a safer alternative to smoking, by vape manufacturing brands and smokers, but they can be more addictive and deliver more nicotine to those who use them, say scientists

June 02, 2023 12:19 pm | Updated June 03, 2023 04:49 pm IST

Image for representational purpose only.

Image for representational purpose only. | Photo Credit: Getty Images

On World No Tobacco Day, when countries are pressed into performing, the Union Ministry of Health has directed OTT platforms to run anti-tobacco health spots and warnings, notifying the amended rules under the Cigarettes and Other Tobacco Products Act, 2004. However, e-cigarettes, or vaporisers, or vapes that contain nicotine, a tobacco extract, do not fall under the rule. 

In India, the Union Government banned the import, manufacture, and sale of vapes in 2019, prompted by both health and safety concerns (with vapes exploding). Despite this, many made-in-China disposable single-use devices and refillable ones are brought into the country through the black market, and routed through a third country. They are openly sold in city stores, and the government has issued additional advisories, with the most recent one in May, to warn vape sellers and users of the consequences of flouting the ban. 

A study, ‘E-cigarettes: A continuing public health challenge in India despite comprehensive bans’, published this year in Preventive Medicine Reports, found that “Those with higher levels of education are among those most likely to vape.” Of the 840 tertiary-educated young adults who were surveyed, 8% were found to be dual users of e-cigarettes and tobacco, but 31% were curious about using them and 23% said they would try them the following year. 

Vape advocates consist of users and e-cigarette manufacturers. The first set, often bolstered by the second, talk about “tobacco harm reduction”, saying they are transitioning to a “smoke-free” future.

Monika Arora, director of the Public Health Foundation of India’s (PHFI) Health Promotion Division, said that a complete prohibition was the appropriate course of action for India. “With countries that have regulated e-cigarettes, so much time is spent discussing which flavours to allow or prohibit in the market, whereas India’s approach of complete prohibition has saved the time of policymakers, and protected the current young generation from this deadly exposure, which would have made them a nicotine dependent generation.” The PHFI played a key role in the policymaking process leading up to the e-cigarette prohibition.

Vaping harms

Opponents of vaping — especially regulators — are watchful of two main problems with vapes: one, that while the carcinogenic risk associated with combustible cigarettes doesn’t immediately appear to be a pressing concern, the long-term risks are unknowable, as it takes time to assess safety through controlled studies, and the fact that nicotine is a very addictive substance. Two, these fears are bolstered by the increased concentration of nicotine in typical vapes, and the social ease with which vaping can be done indoors. (Vapes generally don’t leave a lasting odour.)

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“Vaping patterns differ from cigarette smoking,” Gideon St. Helen, an assistant professor at the University of California, San Francisco’s Department of Medicine, concluded in a 2016 study that focused on how e-cigarette users spaced out their intake. St. Helen found that the “interpuff interval” among 13 vape users was just about two minutes. “Differences in delivery patterns and peak levels of nicotine achieved could influence the addictiveness of e-cigarettes compared to conventional cigarettes,” he wrote in his observations. 

Also, since vaping is less off-putting to those who might be discouraged by the harsh experience of smoking a combustible cigarette, it is easier to form a habit around nicotine consumption that may not have otherwise been there. “Minimising harshness and adaptive to user experience, [vape brand] Juul’s design facilitates initiation to a high nicotine, and ultimately, highly addictive vaping product,” said the study titled Nicotine delivery and cigarette equivalents from vaping a Juulpod by the Stanford Prevention Research Center, referring to the popular American vape brand.

Youth use

Policymakers may specifically view the use of vapes by young people cautiously. “Though the prevalence of youth e-cigarette use in India remains unknown, paediatricians are often brought to provide care to youth who vape,” said a paper ‘E-cigarettes and Vaping: A Global Risk for Adolescents’ published in Indian Pediatrics in 2021. “Use of nicotine during adolescence is associated with altered brain development and long-term impairments in memory, attention capacity and executive functioning,” Swati Y. Bhave and Nicholas Chadi wrote. 

“Consuming large amounts of nicotine through vaping can lead to nicotine toxicity, which presents with headaches, abdominal pain, nausea, vomiting, heart palpitations, hand tremors, difficulty concentrating, and in some cases, seizures and cardiac arrhythmia. Nicotine is also a long-term risk factor for poor cardiovascular health.”

“The parts of a developing brain, those responsible for attention, learning, memory — those are affected by nicotine,” says Ms. Arora.

Smoking cessation

The highest profile conflict between regulators and e-cigarette manufacturers has been that between the United States and Juul. After initially getting into trouble over flashy marketing that was criticised as appealing to young people, the firm shifted away from splashy colourful hoardings to more sober messaging, with video testimonials from adult smokers who had switched to e-cigarettes.

However, cigarettes are not the only nicotine delivery methods that are legal in India. Patches and nicotine gums are prescribed for smokers looking to quit, but find it difficult to go cold turkey. Unlike vapes, though, these have a delayed response in the brain, as their dosage is limited to the content of a cigarette, between 1 and 4 milligrams.

“The nicotine dependence levels measured with the Fagerström test for nicotine dependence were shown to be over two times higher among e-cigarette users compared to traditional tobacco smokers,” Ms. Arora said. “Also, among dual users [using traditional cigarettes as well as e-cigarettes], nicotine dependence levels were higher” than if they only smoked traditional cigarettes, she added.

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