Health experts debunk myths on vaping: Does it really help smokers quit? What chemicals are you inhaling?
E-cigarettes are banned in Singapore and getting caught vaping will get you a hefty fine, but that hasn’t stemmed the rising number of offence cases in recent years. CNA Lifestyle asks doctors and pharmacists all about vaping.
When it comes to cigarette use, its association with lung disease, cardiovascular disease, cancer and congenital deformities is well-documented. Even if you aren’t aware, pick up any cigarette pack and you’ll see graphic images of one of those medical conditions printed on it.
E-cigarettes or vapes, on the other hand, are marketed openly on social media platforms and messaging apps as colourful accessories. The fruit-scented plumes that the battery-operated vaporisers (also known as vape pens, electronic cigarettes or e-cigarettes, and electronic nicotine delivery system or ENDS devices) produce are also mistakenly perceived as less harmful than the acrid odour of cigarette smoke, even though vaping has been linked to sometimes fatal lung disease.
Vaping is banned here in Singapore. Anyone found guilty of possession, use of or purchase of e-vaporisers could get fined up to S$2,000, and those found importing or selling them risk fines of up to S$10,000 and up to six months' jail.
Controversially, the US Food and Drug Administration (FDA) authorised the sale of three vaping products to adults last October to help smokers quit or reduce their cigarette use. "The FDA determined that the potential benefit to smokers who switch completely or significantly reduce their cigarette use, would outweigh the risk to youth," it said.
ARE SINGAPOREANS SECRETLY USING VAPING TO QUIT SMOKING?
But what about the situation in Singapore? Are adult smokers here using vaporisers on the sly to help them kick the smoking habit?
“There is no available data as vaping is illegal in Singapore, making people not forthcoming,” said Dr Puah Ser Hon, a consultant with Tan Tock Seng Hospital’s (TTSH) Respiratory & Critical Care Medicine.
One thing’s for sure: More vaping offences have been recorded over the years. Citing recent statistics from the authorities, Dr Kenneth Chan, a consultant respiratory physician with Respiratory Medical Associates, said that the number has almost tripled from close to 2,500 in 2019 to more than 7,500 in 2021. “This statistic highlights the prevalence of the activity and its growing trend despite the ban,” he said.
Dr Chan added: “I don’t keep track of how many vapers I’ve seen in my clinic, but it is common enough for me to ask my patients about a vaping habit routinely.”
Grace Chew, a senior pharmacist at Guardian, has also noted the reluctance of customers to reveal if they are indeed using the devices. However, the pharmacists do get asked “general questions” by one out of every seven customers, she said.
IS VAPING AN EFFECTIVE TOOL TO HELP YOU KICK SMOKING?
Despite the FDA's reasoning and some research supporting its position, other studies have found “very low certainty evidence” that e-cigarettes are the way to give up cigarette smoking in the short term. Neither is there “enough evidence to determine if e-cigarettes are a safe and efficacious means of smoking cessation in the long term” (more than 12 months), said a study published by the American Journal of Health Promotion.
“The available data on the use of e-cigarettes as a means to quit cigarette smoking has been inconclusive, with some data showing some degree of improvement in quit rates, while other studies showed no benefit,” said Dr Puah.
“In one study, although there was an improvement in quit rates, there was prolonged usage of e-cigarettes and there is still no long-term data on the effects of regular inhalation of vaporised fumes through an ENDS device,” he said.
WHY IS VAPING SEEN AS LESS HARMFUL, THOUGH ALSO DANGEROUS?
For one, users tend to consider vaping as less addictive than regular smoking. It does not help that the e-liquid or vape juice that is vaporised by the e-cigarette comes in candy-like flavours. “The aerosol inhaled from e-cigarettes may have nice smells and flavours. It might be perceived in the same vein as sweets or breath fresheners,” said Chew.
Moreover, you don’t have to burn anything to vape, unlike smoking cigarettes, she added. And since there is no burning involved, which people tend to associate with the creation of cancer-causing carcinogens, vaping is “regarded as less harmful”. “Without having to light up, it is convenient to vape undetected anywhere,” she said.
But no matter how you smoke it, these devices still produce nicotine, said Leslie Chua, a senior pharmacist with TTSH. “Nicotine is a known addictive chemical and has been found to lower the threshold for addiction and a gateway drug to marijuana and cocaine. It has also been shown to affect brain development.”
The same misconception could also come from being told that the nicotine used is “extracted and purified from raw tobacco, hence their perception that there are fewer toxic chemicals compared to cigarettes”, said Dr Chan.
VAPE JUICE CONTAINS THC AND VITAMIN E ACETATE – WHAT DO THEY DO?
Other than nicotine, an outbreak of lung injuries and deaths associated with vaping in the US in 2019 has identified two other chemicals as dangerous: Tetrahydrocannabinol (THC) and vitamin E acetate. THC is the “main psychoactive compound in cannabis that produces the associated ‘high’ feeling when consumed”, said Dr Puah.
“THC’s use in vaping has gained popularity in many parts of the world. This is fuelled by companies that market their THC-containing products with purported benefits for sports or personal wellness. However, it is actually cannabinol or CBD that shows potential for various medically indicated uses,” he said.
As for vitamin E acetate, it is an oily chemical usually used to dilute THC, said Chua. “THC vaping cartridges that are sold commercially are usually formulated with such oils to improve its consistency.”
But here’s where the “vitamin E” part of the name might dupe users into regarding it as benign or even beneficial. While it is fine to apply vitamin E acetate on skin or ingest it as a supplement, it is another matter to inhale it.
Case in point: The US’s aforementioned spike in the vaping-related condition dubbed “e-cigarette or vaping product use associated lung injury” or EVALI. The Centers for Disease Control and Prevention found vitamin E acetate in the lungs of patients who vaped, and the chemical was strongly linked with shortness of breath, cough and chest pain that saw more than 2,800 hospitalised and 68 dead.
TIPS TO FIGHT THE URGE
Resisting the urge to light up is probably one of the hardest things to do when you are trying to quit smoking. “But remember that the urge won’t last forever and will likely pass within 5 to 10 minutes,” said June Lim, Tan Tock Seng Hospital’s senior psychologist. Here are some tips from her:
- Avoid triggers: Identify the timings, places and situations where you are most likely to get a craving. Next, either avoid or replace them with another activity that preferably involves your hands because you cannot smoke when your hands are busy.
- Delay lighting up: Tell yourself to wait for a while. Then, do something such as drinking water, eating a sweet or distracting yourself. The urge will eventually pass.
- Practise deep breathing: Most people use smoking as a coping mechanism to deal with stress. Deep breathing is a powerful tool to help you relieve stress and overcome cravings.
- Get support: Find support from friends who are also thinking of quitting or find friends, family or loved ones who will support and encourage you. You can message or call them whenever you have the urge to light up. Make an open announcement to everyone that you are quitting as this commitment will increase your chance of success.
- Remind yourself why you want to quit: It could be you want to be healthier, feel more energetic, for financial reasons or even for the sake of your loved ones. Listing down your reasons helps to reaffirm what really matters and why you began this journey of quitting in the first place.
OTHER CHEMICALS FOUND
No matter how vaporiser manufacturers market them, e-liquids or vape juices contain cancer-causing substances such as formaldehyde, benzene, carbonyls, and other volatile organic compounds, as well as toxic heavy metals like lead, nickel and tin, said Dr Chan. “The potential long-term effects of e-cigarette consumption still require more medical research, so it should not be taken lightly.”
Here’s a look at the list of chemicals that are commonly found in e-cigarettes:
- Propylene glycol and vegetable glycerine: These liquids can lead to lung inflammation.
- Diacetyl: This yellow liquid with a buttery flavour causes bronchiolitis obliterans or "popcorn lung", where the tiny air sacs in the lungs are scarred, resulting in the thickening and narrowing of the airways.
- Acrolein: This sharp, acrid liquid can irritate the nose and throat; and cause dizziness, nausea, headache, and passing out. High concentrations can lead to loss of consciousness and death.
- Diethylene glycol: A colourless, odourless liquid with a sweet taste, it can cause abdominal pain, vomiting, diarrhoea, headache, altered mental status and acute kidney injury.
- Heavy metals such as nickel, tin, lead, cadmium and benzene: The inhalation of these ultrafine particles can lead to lung damage.
And that’s just the tip of the iceberg before the e-liquid is burned. “E-liquids have been shown to contain at least 100 chemical compounds,” said Chua. That number may be lower than the 7,000 chemicals that conventional cigarettes produce, but that’s because you haven’t started up the vaporiser yet.
“More compounds are usually detected in the aerosol produced as new chemicals are generated during the vaporisation process,” said Dr Puah. “Although e-cigarettes may seem to produce fewer chemicals, almost all of the known chemicals emitted by e-cigarettes are known to be potentially harmful compounds and pose a general health risk to both the users and their loved ones.”