Electronic cigarettes and the use of e-liquids

By Mariano Garcia de Palau

Born in Barcelona, 17 February 1956. Graduated in medicine and surgery from the University of Barcelona in 1979. For 38 years has worked as an emergency physician in the area of occupational medicine. He became interested in cannabis by chance, and for the last 15 years has studied its therapeutic uses. He currently works at Kalapa Clinic, where he advises on treatments with cannabinoids, performs clinical work with patients and collaborates with different organisations and associations such as Catfac. He is a member of the Spanish Observatory for Medicinal Cannabis. He is a regular member of IACM.

Electronic cigarettes and the use of e-liquids with or without nicotine are designed to help smokers quit smoking. Starting from this premise, an inhalation should produce a quantity of steam similar to a cigarette draft. Other uses such as generating huge clouds, or performing dexterity competitions with steam, are far from the purpose of the interesting device, but human mammal always finds how to justify debatable uses of almost everything that passes through its hands.

There are studies that indicate that the reduction of risks achieved with the use of electronic cigarettes, with respect to tobacco consumption, can reach 95%, which is a really interesting figure, provided that the use is correct, and this includes the quality of the electronic device, the composition and quality of the e-liquids, and a moderate and reasonable consumption. I think this last tip is applicable to all substances we consume and the activities we do.

All e-liquids on the market are basically comprised by Propylene Glycol, or PG, and Vegetable Glycerin, or VG, in different proportions or percentages, and flavorings. They may also contain distilled water in a small percentage. And they should not contain any other type of additives, which is an important fact as we will see later.

There are e-liquids on the market with CBD and terpenes, in different percentages of CBD and terpenic profiles. In this case the terpenes could be classified as flavorings. The legislation in force in Europe prohibits the commercialization of products with CBD as a food supplement, but their use in e-liquid would not be food.

Propylene glycol (PG) should be the basic component used in e-liquids; it is a colorless, tasteless and odorless organic alcohol compound. The acute oral toxicity of a single dose of PG is very low. Chronic oral toxicity too. Due to this low oral toxicity, PG is generally recognized as safe for many years, and even bactericidal properties have been attributed to it.

As for its applications, they are very wide: as a humectant in pharmaceutical, cosmetic, food and tobacco products, as a flavoring and coloring solvent in foods (cheeses, ice creams, milks, etc.) and drinks (food additive E1520), as antifreeze food, in artificial smoke machines for firefighters training and theater productions, as an ingredient in cosmetics, baby products, in many medicines, hand sanitizers, antibacterial lotions and saline solutions.

Until now, in the countries of the European Union its use in foods for human consumption is regulated by the Directive of the European Parliament and Council N ° 95/2 / EC for food additives that are not dyes or sweeteners. Its carcinogenesis has also been studied being the result negative.

All these studies refer to the use of PG orally or topically, but there are not many studies on its administration or use by inhalation in the medium and long term. But it must be taken into account that electronic cigarettes have been used for 16 years, and no pathology that can be related to a correct and reasonable use of these devices has been epidemiologically detected.

Vegetable glycerin, or glycerol (VG) is a clear, odorless liquid, made from plant oils, especially palm oil, soy or coconut oil. The VG has a number of valuable applications that include cosmetic products, food and as a substitute for alcohol in botanical and herbaceous tinctures.

The vegetable glycerin used in food processing is endorsed by the US Pharmacopoeia. (USP), must have a purity greater than 99% and has a sweet taste. Vegetable glycerin is metabolized differently from sugar and is used in low carbohydrate foods to provide sweet taste and moisture. Unlike sugar, glycerin does not generate dental problems.

VG can be used as a diluent and as a substitute for alcohol to prepare herbal extracts or tinctures. This is an advantage for people who want to avoid exposure to alcohol.

Vegetable glycerin, due to its lipid characteristics, can generate respiratory problems when consumed in excess, we always have to check the percentage of VG contained in e-liquids, , the higher, the more likely to generate problems if we consume it in excess. Health problems arising from the use of electronic cigarettes are directly related to the percentage of VG, the higher the percentage, the more likely to have respiratory problems.

Before entering this topic, we will go back to 2014. The first case of lipoid pneumonia diagnosed in Spain (the second in the world) was diagnosed in A Coruña in 2014. The patient, an "important smoker," consumed about two daily packets of tobacco. But when he 'switched' to the electronic cigarette he came to consume five daily charges, the equivalent of five packs. His addiction intensified in such a way that this consumption of e-liquids with a high percentage of vegetable glycerin, put his life at risk, and had to be admitted to the hospital until his recovery. After being discharged, the man has returned to traditional tobacco, although he tries to moderate his consumption. What generated the problem was the accumulation of vegetable glycerin, a lipid that accumulated in the patient's lungs, preventing proper oxygenation. "If the consumption of electronic cigarettes is maintained, in a short time more cases of lipoid pneumonia can be diagnosed," said Carlos Jiménez, director of smoking research at the Spanish Society of Pneumology and Thoracic Surgery. And it goes further: "It is a disease that can be serious and even fatal if it affects a person with a previous insufficiency" (3). Obviously, this consumption is excessive, and it is certain that the e-liquids contained a VG percentage of at least 50%, which facilitates the appearance of problems, always in relation to the abuse and the percentage of VG. To date, no other lipoid pneumonia has been detected again despite the obsolete regulation of products and the misuse of electronic cigarettes made by many users.

What is happening in the USA today? An "epidemic in vapers" appears that present serious respiratory problems, in relation to the inhalation of e-liquids that contain THC. This was the initial news!

The first medical analysis is oriented towards lipoid pneumonia, but it is soon ruled out:

"While we cannot rule out the potential role of lipids, we have not seen anything that suggests that this is a problem caused by the accumulation of lipids in the lungs. Instead, it seems to be some type of direct chemical injury, similar to what one might see with exposures to toxic chemical fumes, poisonous gases and toxic agents, "says Brandon Larsen, MD, Ph.D., surgical pathologist at Mayo Clinic Arizona and national expert in pulmonary pathology (1).

The health problem generated in the USA, and which has been directly related to the use of electronic cigarette and THC, deserves a thorough analysis, since the explanation is simple, but unfortunately as of the date of this writing 39 people have died and more than two thousand have sequelae or are seriously ill. If we are using contaminated e-liquids, or wrongly formulated with toxic products, we will have problems. If the components of an electronic cigarette, such as the tank for the e-liquid, are contaminated by bacteria or fungus, or it is handled and filled without the necessary hygienic conditions, we have a problem. Many users of electronic cigarettes make their own e-liquids, or worse, they commercialize them in a market without regulation or control, and therefore, the hygienic conditions and the quality of the products used, will determine if the final product is suitable for consumption, or can cause problems. If we have used a cannabis-derived product to make an e-liquid, if the herb or extract is contaminated, with pesticides or heavy metals, for example, the final product will generate problems in the short or medium term, and it no longer even depends on the use of electronic cigarettes. If the components of the e-liquid are not correct or the concentrations are wrong, we can, evidently, even generate deaths.

Tocopherol acetate (vit E) that has antioxidant properties, and is used in the food or pharmaceutical industry, has been one of the causes of this disaster, since the company Honey Cut (2), has been marketing an alternative diluent to the PG and VG, with an explosive composition, of 90 to 95% pure vitamin E acetate !, and the rest other forms of vitamin E. Honey Cut has also achieved very high market levels in diluents of e-liquids, so this fact has aggravated the number of those affected. If we follow the production chain, this diluent of Honey Cut, already very problematic, reaches for example the Huffhines brothers(5), of Wisconsin, already accused, who make a mixture of the diluent with cannabis extract contaminated with myclobutanyl, hexane, butane, propane, etc. Neither the hygienic conditions are correct, nor the knowledge to make these formulations. In the state of California alone, there are about 2,800 stores that sell these products without any control; which leaves the situation in the hands of the government, which must face the problem and regulate this market to avoid serious health problems, which are generated by the lack of regulation and control of the products.

But the initial intention has been clear, to take advantage of the situation to attack the electronic cigarette and the cannabis, without any objective data, and with scientific confusion, accompanied by a lack of knowledge on this issue by the social agents who have managed the crisis . We also have to value the products that arrive from the Chinese market, without the controls or the necessary information about the products and their composition. I think it is a global problem to regulate this market, since we can avoid health problems and take advantage of a very useful resource for smokers who want to quit the toxic habit of tobacco, which has so many negative implications on our health. If we value the recent information, it has become clear that the states that have regulated the cannabis market have been able to better control the situation by being able to exercise more effective control to withdraw illegal products. Most cases have occurred in states without regulation. It is clear that the black market and the lack of regulation are the basis of the problem in the USA. It must be said in his favor that in the state of California (5), in the last year and a half, cannabis products and batches of licensed cannabis (about 5000) have been removed, due to incorrect labelling, presence of pesticides, residual solvents, or heavy metals Legal access to these products makes their control effective, or does not exist. Obviously, it is clear that the problem that has cost many human lives, does not have anything to do with the electronic cigarette, nor with the habit of vaping, the cause is the lack of regulation and control of this market. I hope that this situation does not influence the legislative attitude of other countries, as happened with cannabis in the middle of the last century, and culminated with the signing at the UN convention in Geneva in 1961, in which cannabis became a narcotic on list 1.

With responsible vaporization and quality control of e-liquids, in addition to the use of suitable vaporizers, we can reduce the possible risks of e-liquids consumption, and if we compare the risks of vaping with tobacco consumption, we can reduce considerably the health problems derived from its use. In fact, vaporization is an alternative to abandon tobacco consumption, and if it replaces it, the health benefits are more than remarkable. The quality of the flavorings, CBD or terpenes, that we can find in the different e-liquids, is fundamental to avoid problems derived from toxicity or even contamination. Many vapers use e-liquids whose composition they do not know, and it really should be the governments that regulate and do not prohibit, even if it is easier for their abilities, these alternatives to smoking that so much concern some pharmaceutical companies like Pfizer, with their product Champix (Varenicline), which is the only product in Spain financed by the public health system, to wean people from tobacco. According to the newspaper Der Spiegel (4), this pharmaceutical company has been financing campaigns against the electronic cigarette in Europe, and if this news is true, it is because they are worried about losing market with their pharmaceutical product, given the effectiveness of the electronic cigarette to leave the smoking habit. Obviously, the use of the electronic cigarette does not assure us of the success in tobacco cessation, the main tool is the willpower and the motivation to quit.

Technical tips for the use of electronic cigarettes

We propose a countercurrent use, since currently the use of electronic cigarettes encourages sub-ohm vaporization, with very low resistances of 0.15 / 0.30 ohm, and powers greater than 200W in some devices, which translates into almost immediate incandescence of the resistance, which generates temperatures of up to 400º. By adding a high proportion of VG in the e-liquid (40 to 80%), an extraordinary amount of steam is achieved. But we do not get the best flavor, its use is focused on the production of steam in large quantities, not on getting complex flavors with many nuances.

Is this a logical use of the electronic cigarette? We think not.

The vaping sessions should be productive, but we do not have to expect lush clouds of steam, we opt for a reasonable amount of steam, which can mimic a cigarette draft. This will be achieved with e-liquids with low VG percentages, at most 20% would be advisable, but we do not currently find them in the market with this formulation! The problem is the VG, the PG is safer, although probably not harmless. Reasonable consumption and correct use.

The taste level can be increased if we use resistors of 1 to 2 ohms in our atomizers, both repairable, and "all in one", which translates into a slower increase in temperature, without reaching the incandescence of the resistance, and therefore at high temperatures (300º to 00º). These temperatures can generate compounds such as acroleins or formaldehydes, and they are not necessary to transmit e-liquids. Therefore, we minimize the efficient generation of carcinogenic substances, if we compare with those derived from the combustion of a cigarette. We also advise to vaporize between 15w to 30w, in vaporizers with watt control. The "pods" vaping devices that we find in the market already follow these guidelines, sanity and logic have been installed in these devices, finally, if we compare with the use of "mods" and atomizers with 0.15 resistors Ohm and up to 200 watts of power! Fast incandescence of the resistance and high temperatures that can cause carcinogens, always in relation to the quality of the components of the device and obviously of the e-liquid.

Do not forget the maintenance and periodic cleaning of the tank, for example, with isopropyl alcohol and warm water, and also renew the resistances depending on the frequency of use. If we change e-liquid without cleaning the tank and changing the resistance, the flavors will be mixed initially. For foodies, having several atomizers allows you to taste the different e-liquids without mixing flavors. Keep in mind that you should not use up the atomizer's e-liquid, because you can burn the cotton and the burning taste is inevitable, we have to change the resistance, or repair it if we use repairable atomizers.

Electronic cigarettes are not intended to start vaping as a first step to the subsequent consumption of tobacco, nothing is further from its indication. We believe that they are interesting for tobacco smokers who want to have a support in the substitution of cigarettes for the habit of vaping, which greatly reduces the risks of smoke inhalation after cigarette combustion.

I will continue to defend the use of electronic cigarettes, always adopting the risk prevention measures that we recommend and their consumption philosophy.

Bilbiography consulted

Análisis, diseño e implementación de una guía de iniciación al vapeo - Autora: AINHOA SALGADO VALDÉS Leganés, octubre de 2015 Proyecto fin de carrera ingeniería técnica en informática de gestión.

Cigarrillos electrónicos: toxicidad, adictividad y potencial utilidad terapéutica - F. Javier Ayesta Ayesta director del Máster en Tabaquismo Universidad de Cantabria Mª Jesús García-Blanco presidenta de la Sociedad Española de Especialistas en Tabaquismo (SEDET) Francisco Rodríguez-Lozano Presidente del Comité Nacional de Prevención del Tabaquismo (CNPT).

Evidence review of e-cigarettes and heated tobacco products 2018 A report commissioned by Public Health England - Authors: Ann McNeill 1,2, Leonie S Brose1,2, Robert Calder1 , Linda Bauld 2,3,4, Debbie Robson 1,2. / 1 King's College London 2 UK Centre for Tobacco & Alcohol Studies 3 University of Stirling 4 Cancer Research UK.

House of Commons Science and Technology Committee E-cigarettes Seventh Report of Session 2017–19 Report, together with formal minutes relating to the report Ordered by the House of Commons to be printed 16 July 2018 - Science and Technology Committee The Science and Technology Committee is appointed by the House of Commons to examine the expenditure, administration and policy of the Government Office for Science and associated public bodies. Current membership Norman Lamb MP (Liberal Democrat, North Norfolk) (Chair) Vicky Ford MP (Conservative, Chelmsford) Bill Grant MP (Conservative, Ayr, Carrick and Cumnock) Darren Jones MP (Labour, Bristol North West) Liz Kendall MP (Labour, Leicester West) Stephen Metcalfe MP (Conservative, South Basildon and East Thurrock) Carol Monaghan MP (Scottish National Party, Glasgow North West) Damien Moore MP (Conservative, Southport) Neil O'Brien MP (Conservative, Harborough) Graham Stringer MP (Labour, Blackley and Broughton) Martin Whitfield MP (Labour, East Lothian) Publication Committee reports are published on the Committee's website at www.parliament.uk/science and in print by Order of the House. Evidence relating to this report is published on the relevant inquiry page of the Committee's website.

Vaping saves lives. It'd be madness to ban it David Nutt
Cigarettes kill. Anything that makes some smokers give them up is to be encouraged - Fri 14 Oct 2016 13.03 BST.

1) Vaping-associated lung injury may be caused by toxic chemical fumes, study finds October 2, 2019 Mayo Clinic.

2) From 'Veronica Mars' to toxic vapes: The rise and fall of Honey Cut By Marissa Wenzke, with David Downs November 8, 2019 Leafly

3) Diagnostican el primer caso de neumonía por 'vapear' El mundo 2014.

4) La farmacéutica Pfizer, acusada de financiar campañas contra el cigarrillo electrónico. El economista.es - Javier Romera 28/08/2019.

5) Leafly

Image: "Vaping" by Lindsay Fox is licensed under CC BY 2.0