July
08, 2020| By Dr. Thomas Ashley
In my first blog in my series on vaping, I described the
characteristics of the large, global vaping population. Life insurers care most
about the health consequences of e-cigarettes. This segment will touch on
several aspects of this concern.
The common thread between conventional smoking
and vaping is nicotine. Just like in studies of tobacco smokers, studies of
vapers show increased heart rate and blood pressure in proportion to nicotine
levels.1 So far research has not found an association between
e-cigarette use and cardiovascular disease.2 But given the
relatively young population of vapers and short duration of use of this new
product, this initial research is not strong evidence of safety.
Long-Term Health
Effects of Vaping
Because the e-cigarette product is so new, direct
observation of long-term health outcomes does not exist. Examination of
surrogate evidence provides a way to address the problem: One form of surrogate
evidence examines clinical effects that can develop more quickly than
mortality. When smokers with asthma switch to e-cigarettes, lung function and
respiratory symptoms improve. Smokers with COPD who switch have fewer
exacerbations. However, animal and in vitro studies suggest adverse effects in
the respiratory system result from e-cigarette exposure.3 Moreover,
in both healthy human volunteers and patients with asthma or COPD, vaping for
10 minutes triggers significant airway obstruction.4
Cancer risk accumulates slowly, and it is too
soon to obtain direct evidence. Heating the vaping solution produces a chemical
mix that is far simpler than tobacco smoke. Still, it generates formaldehyde
and other molecules that are potentially risky. E-cigarette aerosols can create
DNA damage in laboratory models. The level of exposure may or may not reach a
level to induce cancer.
Dangerous Ingredients?
More is known about the health effects of some
of the typical constituents in the vaping aerosol itself. To maintain moisture,
e-cigarette compounds commonly contain propylene glycol or glycerine. The
European Commission does not classify propylene glycol as hazardous, even
though studies have shown that it may induce respiratory symptoms and release
of inflammatory mediators. Extensive vaping can create exposure close to the
level of occupational exposure limits for propylene glycol.5
Flavoring is extremely variable with thousands
of unique e-liquid varieties. Some of them are generally regarded as safe for
ingestion. Inhalation may or may not exhibit similar effects. Others have a
potential respiratory health hazard. The biggest unknown, however, relates
to impurities and undocumented ingredients that may exist in the products of
innumerable suppliers around the world.
Assessing Risk of Lung
Injury
The importance of specific ingredients became
obvious with the discovery of e-cigarette, or vaping, product use-associated
lung injury (EVALI). As of February 2020, the CDC reported
2,807 hospitalizations and 68 deaths in the U.S. The outbreak peaked
in September 2019.6
In 2020 so far, the CDC reports that the
incidence rate is <10 cases/week, and 82% of cases reported use of
THC-containing products. Among those, 78% obtained their inhalant from informal
non-commercial sources (friends, dealers, or online). Many THC products add
Vitamin E to the solution as a diluent. Vitamin E is an oil and EVALI
resembles a condition called lipoid pneumonia that develops from deposition of
fats or oils in the lung. It is obvious that any assessment of the effects of
vaping must separate these products from the commercial manufactured offerings
of nicotine and flavorants.
Right now, research tentatively shows that
vaping poses lower health risk than smoking tobacco.
In my next blog, I will examine estimates of
harm and consider the implications if insurers wish to differentiate the risk
of vaping from smoking and nonsmoking. In the meantime, if I can help you think
through this medical underwriting issue for your company, feel free to
reach out.
Endnotes
1.
U.S. Department of
Health and Human Services. E-Cigarette Use Among Youth and Young Adults.
A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf.
2.
Osei AD,
Mirbolouk M, Orimoloye OA, et al. Association between
e-cigarette use and cardiovascular disease among never and current
combustible-cigarette smokers [published online ahead of print March 8,
2019]. Am J Med. https://doi.org/10.1016/j.amjmed.2019.02.016.
3.
H-W Lee,
et al. E-cigarette smoke damages DNA and reduces repair activity in mouse
lung, heart, and bladder as well as in human lung and bladder cells. PNAS
February 13, 2018 115 (7) E1560-E1569; first published
January 29, 2018. https://doi.org/10.1073/pnas.1718185115.
4.
Pisinger C,
Dossing M. A systematic review of health effects of electronic
cigarettes. Prev Med 2014;69:248-260. https://doi.org/10.1016/j.ypmed.2014.10.009.
5.
Behrakis,
Panagiotis & Vardavas, Constantine. (2016). PRECISE (Potential Risks
from Electronic Cigarettes & their technical Specifications in Europe)
Project. doi:10.2818/422906.
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