smoking

E-Cigarette Flavorings: A Taste of CVD?

Although much remains to be learned about the long-term health effects of e-cigarettes, most e-cigarettes contain substances—such as nicotine—that are known to be harmful to the body.1

With the availability of portable, easily hidden devices and a wide variety of vapor flavorings on the market, e-cigarettes and their chemical components pose a rapidly growing health concern in the United States, especially among youth.

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With this in mind, Jessica Fetterman, PhD, assistant professor of medicine at Boston University School of Medicine in Massachusetts, and colleagues specifically aimed to determine the effects of e-cigarette flavorings on cardiovascular health in a new study.2

The results of the study showed that most of the flavorings tested were associated with various negative cardiovascular health effects including impaired nitric oxide production, which is often one of the first bodily changes to precede the development of cardiovascular disease.

Consultant360 recently spoke with Dr Fetterman about the new findings and their health implications among users of these increasingly popular products.

Consultant360: How do e-cigarettes compare with regular cigarettes in terms of safety and health impact?

Jessica Fetterman: Very few studies on the health effects of e-cigarettes have been completed and published, so I think it is premature to say that e-cigarettes are harmful or safe. We do know that some of the heart disease-associated chemicals found in regular cigarettes are found in e-cigarettes, which is a cause for concern. One cigarette imparts most of the heart disease risk of smoking, so even if e-cigarettes contain lower levels of the toxic chemicals, they may still impart a similar risk for heart disease. So, e-cigarettes are likely not without risks, but the extent of the health risks is really unknown at this time.

C360: Many people use e-cigarettes as a bridge to quit smoking, but are they more or less addictive than regular cigarettes?

JF: The data suggests that e-cigarettes are as addictive as regular cigarettes and deliver the same levels of nicotine. Most e-cigarette users subconsciously change their inhalation patterns in order to obtain the same amount of nicotine as they would when smoking a cigarette, which likely makes it difficult to completely quit. The addictiveness of e-cigarettes is reflected by the fact that the majority of smokers who use e-cigarettes fail to completely switch to e-cigarettes and fail to quit both regular and e-cigarettes.

C360: Your study ultimately found that flavorings have negative cardiovascular effects. Which ones are the worst and for what reasons?

JF: Five flavoring additives—vanillin (vanilla flavoring), menthol (mint flavoring), cinnamaldehyde (cinnamon flavoring), eugenol (clove flavoring), and acetylpyridine (burnt flavoring)—all impaired the ability of the endothelial cells to produce a molecule called nitric oxide. Nitric oxide is heart-protective in that it inhibits inflammation, prevents blood clots from forming inside blood vessels, and helps regulate the blood vessels to direct blood flow to different tissues at different times.

The loss of nitric oxide has been associated with cardiovascular outcomes like heart attacks and stroke. The fact that these flavoring additives all impaired the cells’ ability to produce nitric oxide is of great concern.

C360: How do your results affect clinicians in practice? What do you hope clinicians learn from your study?

JF: Our study suggests that flavored tobacco products, even if they do not contain nicotine, are not without health effects. I recommend clinicians advise their patients to stop smoking and work toward complete cessation of all tobacco products, including e-cigarettes. Clinicians should especially encourage youth to not use e-cigarettes or other tobacco products.

C360: Juul e-cigarettes are growing in popularity in the United States and have led to deaths in teens. How do Juul e-cigarettes factor into your commentary about vapor flavorings, and what public health concerns do they raise?

JF: Juul e-cigarettes contain the same flavoring additives that we tested in our study, so our findings apply to these products as well. Youth and many adults think e-cigarettes simply create a water vapor, which sounds like it would be safe. However, this is not the case, because e-cigarettes including Juul contain nicotine and other chemicals that we know have toxicity. Young adults are particularly sensitive to the effects of nicotine, so the public health concern is that e-cigarettes are a way to addict new generations of future smokers.

C360: What else should clinicians know about Juul e-cigarettes—the next big public health concern in the United States?

JF: The science showing that e-cigarettes are a gateway to cigarette smoking is very strong. E-cigarette companies are blatantly targeting kids with the packaging and flavors they have put on the market. When e-cigarettes are gummy–bear- and cotton–candy-flavored, there is no question who the companies are targeting.

A study performed by the CDC found that most kids who had tried a tobacco product in the last 30 days had used a flavored product.3 So, the marketing of flavored tobacco products is clearly driving youth experimentation, which may create a new generation addicted to tobacco.

For our coverage of Dr Fetterman’s study, click here.

—Christina Vogt

References:

  1. Electronic cigarettes. Centers for Disease Control and Prevention. Last updated May 16, 2018. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm Accessed on June 19, 2018.
  2. Fetterman JL, Weisbrod RM, Feng B, et al. Flavorings in tobacco products induce endothelial cell dysfunction [Published online June 14, 2018]. Arterioscl, Thromb, Vascular Biol. https://doi.org/10.1161/ATVBAHA.118.311156
  3. Corey CG, Ambrose BK, Apelberg BJ, King BA. Flavored tobacco product use among middle and high school students — United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(38):1066-1070. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6438a2.htm?s_cid=mm6438a2_w