From One Puff to Addiction: E-Cigarettes and Human Health

By Simon Bennett

With low prices, high levels of advertising and bright and colourful packaging, is it any wonder that vapes and e-cigarettes end up in the hands of children and teenagers?

            In an email statement, the Department for Education Northern Ireland Press Office were questioned about the impact of e-cigarette and vapes on teenagers. They replied that ‘teaching our young people about their health and wellbeing is a key strand of the statutory curriculum being taught in schools here in Northern Ireland, and it provides opportunities to explore and discuss the dangers and harmful effects associated with smoking including the use of electronic-cigarettes (e-cigarettes)’.  

            According to the Press Officer ‘personal Health is a statutory component within the Personal Development and Mutual Understanding (PDMU) area of learning at primary level and within the Personal Development strand of the Learning for Life and Work (LLW) area of learning at post-primary level.  As with all aspects of the curriculum, the specifics of what is taught and how it is taught is a matter for each school’. This shows that a small framework for teaching children about these issues exist. Since they are still so prevalent in today’s society, is this framework really good enough?   

            The Department for Education added to this, saying that ‘it is a statutory requirement for every grant-aided school to have in place a drugs education policy.  In August 2015, the Council for the Curriculum, Examinations and Assessment (CCEA) published revised guidance, Drugs: Guidance for Schools in Northern Ireland, that was issued to all schools.  A copy of this guidance can be found on CCEA’s website and it includes a section on the dangers associated with e-cigarettes’. The Council for the Curriculum, Examinations & Assessment’s guidance PDF was linked by the Press Officer. Page 4 of the guidance booklet includes a full section on electronic cigarettes. CCEA’s guidance booklet states that ‘we perceive electronic cigarettes to be less harmful than tobacco, there are concerns about their safe use, particularly when children and young people use them, because the electronic cigarette market is unregulated’. According to their guidance booklet, Northern Ireland’s Chief Medical Officer ‘has advised that schools prohibit electronic cigarettes on their premises, in line with tobacco products’. This shows that CCEA and the NI Education Department do see this as a prevalent issue in society. 

            The Press Officer added that during 2014, ‘the Department issued a circular (Circular 2014/25 – Encouraging a Smoke-Free and E-Cigarette Free Environment in Schools and Youth Organisations) reflecting key developments, including legislative changes, the publication of the ‘Ten Year Tobacco Control Strategy’ on the use of e-cigarettes in the school and youth environment. The guidance encouraged schools and youth organisations to extend the ban on smoking in schools and to include a ban on the use of e-cigarettes’ The first point of the curricular specifically states that ‘the purpose of this Circular is to encourage schools and youth organisations to extend the ban on smoking in school and youth premises to include a ban on the use of e-cigarettes’. This does show that the Northern Ireland Education Department are trying to take a stand against e-cigarettes and vapes.

According to a Health Department statement, there are measures in place to avoid these getting in the hands of children. The statement says that during ‘February this year, new regulations were introduced which ban the sale, and proxy sale, of nicotine inhaling products (including parts of the devices)’. A link is included to their policy document. The statement further adds that ‘it is now an offence to sell nicotine inhaling products to children and to purchase, or attempt to purchase, such products by an adult on behalf of a child (a proxy purchasing offence). These offences are in line with offences relating to tobacco sales. The enforcement of the regulations is the responsibility of Tobacco Enforcement Officers in district councils. Enforcement officers have the option of issuing fixed penalty notices of £250 for either offence. An alleged offence may also be referred directly to court and, on summary conviction of either offence, a court can award a fine of up to £5,000. Failure to pay a fixed penalty notice could also result in the matter being referred to court. A person or a business found to be repeatedly selling NIPs [Nicotine Inhaling Products] to children could receive a Restricted Sales Order or a Restricted Premises Order from the court. Such an order can prohibit the sale of nicotine inhaling or tobacco products by a named individual or a business premises for up to three years’. This shows that the Health Department have initiated measures to reduce the amount of vapes and e-cigarettes in the hands of children, however it may be too late. 

            The Health Department were also questioned about how many children have access to vapes. Their response referenced the 2019 Young Person’s Behaviour and Attitudes Survey, which stated that ‘20% of all 11-16 years olds indicated that they had tried an e-cigarette at least once’, ‘6% of all 11-16 years olds reported current e-cigarette use’ and that ‘3% of all 11-16 years olds reported regular e-cigarette use (at least once a week)’. These statistics are surprisingly low and do not back up the hypothesis.

            Dr. Sharon Letters, a dentist says that there is purely not enough evidence to make a decision whether vaping and e-cigarettes are better than tobacco cigarettes. Letters says that ‘I think the first thing to say is that all the current evidence is weak which isn’t great when it comes to practising evidence-based dentistry. Partly not enough studies have been done but also vapes haven’t been around long enough to have long term studies and impacts, unlike cigarette smoking which has obviously been around for decades. So more high-quality, long-term studies are needed to be able to assess the full impact’. Letters says that vapes may be better, depending on the nicotine. Letters says that ‘some vapes do [contain nicotine] albeit in a smaller amount than traditional cigarettes. Nicotine is well documented to be addictive, it restricts blood flow to the gums, so they do not heal or function as well and make the person more prone to gum disease [Periodontal Disease]. This can ultimately lead to tooth loss. It also means that if the patient has any oral surgery, for example a tooth extraction they are at higher risk of the socket becoming infected afterwards and not healing well/delayed healing’. According to Letters this becomes very painful. 

            Letters adds that ‘Propylene glycol is the main ingredient  in vapes. This can dry the mouth and oral mucosa. Dry mouths are more prone to tooth decay [caries] as usually saliva will wash away bacteria and food stuffs but if the saliva isn’t washing things away then tooth decay can be more of a risk. Saliva also helps neutralise the acids made by the bacteria. When someone has a dry mouth, they often drink more or suck sweets. This is not so much of a problem if they are sugar free, but if they drink or suck sugar from drinks and foods then it increases risk further.  Some of the flavourings are also sweet and can be sticky, sticking to the teeth and potentially making the user more prone to decay. People with dry mouths are also more prone to gum disease. It is said propylene glycol also erodes tooth enamel which can cause wear on the teeth. It is unclear whether vapes can cause cancerous changes to the oral mucosa-some studies think there is potential for this’. Letters adds that this will be higher if it contains nicotine, but there is a lack of long-term evidence yet. 

            Letters also adds that ‘there have also been reports of some of the battery units exploding causing burns to the mouth’, showing both the severity of problems from the chemicals and the batteries. 

            According to Letters, vaping may lead to problems with dental enamel. She says that ‘dental enamel loss means the tooth substance is basically dissolved away, resulting in tooth wear and also may leave them more prone to decay. Once the enamel is gone it can’t be brought back. If it erodes away to expose the sentinel below the tooth can become sensitive, discoloured and more prone to decay. It also changes the shape of the tooth and it may be more prone to cracking or chipping’. 

            Letters advises that it is not a good idea for traditional tobacco smokers to swap to vaping, from a dental point of view. She says ‘it would be better for them to go through a proper cessation programme that suits them. My [Letters] personal opinion is that they may still want the nicotine hit and therefore changing to a vape doesn’t have a huge advantage except for removing the tar [and other chemicals] from conventional cigarettes. Alongside this, the temptation to move from a vape back to cigarettes may be too high’. Sharon ended her interview by saying that ultimately ‘there isn’t enough evidence currently to suggest that moving to vape is a lot safer’.

An example of vape and e-cigarette products on display at Sainsbury’s Ballymena. Whilst they are security tagged,
the bright colours and attractive packaging will quickly attract the eyes of a child.

Academic healthcare research seems to advise against e-cigarettes and vaping. According to Parraga and Morissette’s research, ‘exponential growth in recreational e-cigarette use by children and young adults has now provided sufficient, new evidence of harm and it appears that short-term e-cigarette use can result in respiratory distress and failure. Possible causes include the flavouring compounds, adulteration of devices with different lipid solvents, THC or vitamin E and grey or black-market products’. Their research also suggests that ‘patients with lung injury due to e-cigarette use, there was no evidence of underlying lung disease or other conditions that pointed to elevated risk of lung injury and lung failure, nor any evidence of infection’. This shows that vaping is dangerous to people’s respiratory health.

            Ballymena based football coach Callum Ross was questioned about any education he had received about vaping and e-cigarettes. He told me that he has no knowledge of the topic. He said that he never been educated in vapes and e-cigarettes or normal cigarettes, just the problems of alcohol to athletes.  This shows how undertaught these subjects are to modern athletes and coaches. Alongside this, John Lyttle, a first-year Physiotherapy student, with five years of healthcare education, admits that there is a lack of research into the long term effects of using vapes and as such, a lack of education for them to students. In five years of healthcare education, John has very little education on the topic, despite its major risk to healthcare. John says that he knows that ‘you can have nicotine ones and non-nicotine ones’. John also adds that he doesn’t know how much damage they can do, as it is under researched. John adds that they may potentially cause damage to the ‘Alveolar Sacs’, which are ‘small air pockets in the lungs, where gas exchange happens’. This is the same place in the body that damage is caused from tobacco cigarettes, which shows that vaping is just as dangerous as normal cigarettes. The interviews from Ross and Lyttle show how under researched vaping and e-cigarettes are and how underexplained they are to future healthcare professionals and athletic coaches. 

To conclude, we can see that there are some health benefits from vaping over tobacco cigarettes, however they come with many underreported side effects.