REGISTRO DOI: 10.69849/revistaft/pa10202501312118
Cicero Dayves da Silva Bezerra1; Maria Lucia Zarvos Varellis2; Erika da Silva Mello3; Raquel Feliciano da Silva4; Vanessa Dalapria5; Letícia Cristina Cidreira Boaro6; Alessandro Melo Deana7; Thais Rodrigues Galache8
ABSTRACT:
Introduction: Electronic cigarettes, or e-cigarettes, are devices that heat a liquid to produce an aerosol (or vapor) that is inhaled by users. This liquid usually contains nicotine, flavorings, and other chemicals. They were developed as an alternative to traditional cigarettes and are often promoted as a less harmful option for smokers who want to quit. e-cigarettes come in various shapes and sizes, from disposable models to more sophisticated, rechargeable, and customizable ones. A battery powers them and contains a compartment for liquid (e-juice or e-liquid), which is vaporized to mimic the smoking experience. Although some studies indicate that e-cigarettes are less harmful than traditional cigarettes, there are still health risks. Continued use of nicotine can lead to addiction and some research suggests that vaporizing certain ingredients can cause respiratory problems and lung inflammation. In addition, there are concerns about increased use among young people, especially due to aggressive marketing and the variety of flavors available.Objective: Check the current literature on the harmful effects of electronic cigarettes on health. Method: This is an integrative literature review carried out from 2016 to 2024 using the Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO) and National Library of Medicine (PubMed) databases, using the descriptors registered in the Health Sciences Descriptors (DeCS): Intensive Care; Protective ventilation strategies; Invasive Mechanical Ventilation; Adult Respiratory Distress Syndrome. The Boolean operator “AND” was used to define the combination between the terms. The research included articles published between 2016 and 2024, in Portuguese and English, with free access and full-text availability. Monographs and abstracts were excluded from the research. Discussion: the high prevalence of electronic smoking devices, in addition to serving as “starter” products for the consumption of traditional cigarettes and the use of other drugs, makes ESDs anq alarming problem for public health, despite being considered a less harmful means of smoking. The safe use of EC with the release of nicotine has not been proven to be safe for the user’s health. The biggest problem is related to the lack of supervision and necessary regulations regarding the composition of the devices and the amount of nicotine available. Conclusion: the use of electronic cigarettes is harmful both to the user and to the public health and more and more regulations are needed to monitor the dissemination of advertisements and the marketing of the product. It is suggested that further research be carried out to corroborate the harmful effects of EC use, understand its different aspects, and devise strategies to reduce its impact, to improve the population’s health in general.
KEYWORDS: eletronic cigarette, vaping, nicotine, e-liquid, evali
INTRDUCTION
The electronic cigarette also known as (EC or e-cigarette) was created to replace nicotine in order to stop the dependence it brings to conventional cigarette smokers. It consists of a battery, an atomizer, an LED, a sensor, a vaporizer and a cartridge that may or may not contain nicotine. When the user uses the EC by inhaling, the device activates a sensor that detects the air flow and heats the liquid in the cartridge, causing it to evaporate and releasing the nicotine to the user. (Aldy, et al., 2020, Dautzenberg B et al., 2016)
Electronic cigarettes have some differences between them, varying according to the commercial brand. They generally contain nicotine and another component for aerosol production (such as propylene glycol or glycerol diluted in water). Pods are smaller and easier to manipulate their liquid, they also have a higher amount of nicotine and can also be used with herbs. In vapes, the essences are called e-juices, they are composed of a mixture of propylene glycol, vegetable glycerin and the essence (responsible for the flavor), which exhale a greater amount of vapor, in addition to also using oils (THC), and can reach high temperatures. (Aldy et al., 2020, Bertoni, et al., 2021, Dautzenberg B et al., 2016).
With campaigns against the use of conventional cigarettes in mind, the tobacco industry has been renewing itself with the manufacture of electronic cigarettes. Although there is no data proving the efficacy of e-cigarettes for smoking cessation, the tobacco industry has been growing with their manufacture, as well as the spread of e-cigarettes among the younger public, in addition to adults who already consume regular cigarettes. To make them more attractive, these devices are offered to the user with a variety of flavors, the composition of which are volatile organics, heavy metals, nitrosamines derived from tobacco, potentially harmful to health (Dautzenberg B et al., 2016).
There is also a link between social media and electronic cigarettes. More than 90% of young Americans actively use one or more types of social media, under the belief that ESDs offer a safer, more socially acceptable, convenient and enjoyable “smoking” alternative to conventional cigarettes. The regulation of e-cigarette marketing on Internet social media should be reviewed and efforts should be implemented to control their sale and consequent use (Pokhrel et al., 2018, Muthumalage, et al., 2020, Mikheev, et al., 2022).
Because they are not included in the anti-smoking policy, as is the case with conventional cigarettes, e-cigarettes, with or without nicotine, are sold in physical stores and on the internet, making them more easily accessible to users. And because they are seen as less harmful, society has been influenced to consume them, reaching groups of young people and adults more easily (Wagner; Chen; Vrdoljak, 2020, Galo et al., 2020, Doukas, et al., 2020).
There are a variety of ESD cartridges and capsules on the market, as well as a variety of design components, however, there are few studies that demonstrate how these compounds react in the heating element, measuring the content of metal and its “essences” or e-juices (Wagner; Chen; Vrdoljak, 2020, Crotty, et. al., 2020).
Scientific research points to the damage that electronic cigarettes cause to health, generating irritation in the mouth, coughing, headaches, dyspnea, dizziness and also an acceleration of the heartbeat, with impacts especially on the cardiovascular system. In addition, there is an increase in ischemic events and in the respiratory system with lung damage caused by the use of electronic cigarettes (EVALI) (Moreira, SA et al., 2019, Bonner et al., 2020, Bertoni et al., 2021).
Despite being considered a less harmful means of smoking, e-cigarettes should be considered a global public health problem, since their popularity has increased exponentially in recent years, especially among young people. Various harmful effects have been reported involving their use, with damage to users’ health. However, due to the recent emergence and nonspecificity of the symptoms of these pathologies, this study is justified in order to gather the evidence available in the literature about the harmful effects of these devices on health (Alzahrani et al., 2018, Doukas, et al., 2020).
OBJECTIVE
To check the current literature on the harmful effects of electronic cigarettes on health.
METHODOLOGY
This is an integrative literature review carried out from 2016 to 2024 using the Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO) and National Library of Medicine (PubMed) databases, using the descriptors registered in the Health Sciences Descriptors (DeCS): Intensive Care; Protective ventilation strategies; Invasive Mechanical Ventilation; Adult Respiratory Distress Syndrome. The Boolean operator “AND” was used to define the combination between the terms.
The search included articles published between 2016 and 2024, in Portuguese and English, with free access and full-text availability. Monographs and abstracts were excluded from the search. Below is a flowchart of this study:
FLUXOGRAM
Source: Author
A total of 70 articles were found using the search strategy: 8 in Lilacs, 42 in PubMed and 20 in Scielo. After selecting the titles and abstracts, the articles were read in full to select the most relevant articles, which were then included in this study, resulting in a total of 37 articles that made up this review.
The graph below shows the distribution of the articles found in the databases used: LILACS, Pubmed and SCIELO:
Source: Author
| Author | Year | Description |
| Aldy et. al., | 2020 | Number of articles characterizing EVALI and its respiratory and gastrointestinal symptoms related to the use of electronic cigarettes. |
| Alzahrani et. al., | 2018 | They associated the use of electronic cigarettes with an increased risk of myocardial infarction. |
| Bhatt et. al., | 2017 | They studied the impact of occasional and daily use of electronic cigarettes on the risk of acute myocardial infarction. |
| Bertoni et. al., | 2021 | They analyzed the prevalence of e-cigarette users in Brazil, highlighting user profiles. |
| Blount et. al., | 2020 | They identified vitamin E acetate in fluids associated with EVALI. |
| Bonner et. al., | 2021 | They reviewed the chemistry and toxicity of e-cigarette vapors. |
| Chand et. al., | 2020 | They reported pulmonary toxicity related to the use of vaping devices. |
| Crotty Alexander et. al., | 2020 | They have developed a research agenda on lung injuries associated with vaping. |
| Dautzenberg et. al., | 2016 | They have published practical guidelines for health professionals on the use of electronic cigarettes. |
| Doukas et. al., | 2020 | They reviewed cases of lung damage associated with the use of electronic cigarettes. |
| Elsa-Grace Giardina et. al., | 2022 | They addressed the cardiovascular effects of nicotine and its metabolism. |
| Galo et. al., | 2020 | They reported cases of EVALI caused by devices containing THC. |
| Heinzerling et. al., | 2020 | They reported serious cases of lung damage associated with vaping in California. |
| Jiang et. al., | 2020 | They characterized the chemical composition of the vapors emitted by electronic cigarettes. |
| Kaous et. al., | 2020 | They described the clinical and radiological patterns of lung lesions caused by vaping. |
| Kligerman et. al., | 2021 | They identified patterns in CT scans of patients with lung lesions associated with vaping. |
| Mikheev et. al., | 2022 | They analyzed aerosols generatedby mixturesof THC and vitamin E acetate. |
| Muthumalage et. al., | 2020 | They studied the pulmonary toxicity of cartridges containing triglyceride oil and vitamin E acetate. |
| Pokhrel et. al., | 2018 | They investigated the influence of social media on the use of electronic cigarettes among young people. |
| Wagner, Chen e Vrdoljak | 2020 | They examined the chemical composition of the heating elements in vaping devices. |
| Werner et. al., | 2020 | They reported hospitalizations and deaths associated with EVALI. |
| Frazão et. al., | 2023 | They reviewed the risks of e-cigarette use among young people, including addiction and respiratory problems. |
| Moura et. al., | 2024 | They studied the respiratory and systemic effects of using electronic cigarettes |
| Bachur et. al., | 2024 | They reviewed the toxic effects of e-cigarette use on various areas of health. |
| Vieira et al., | 2024 | They discussed lung lesions related to the use of electronic cigarettes. |
| Sousa et. al., | 2023 | They addressed the association between the use of electronic cigarettes and the development of carious lesions. |
| Galo et. al., | 2020 | They reported cases of EVALI associated with the use of THC devices. |
The final sample consisted of 37 articles. In this sense, it is important to note that articles from the last 8 years were selected.
The high prevalence of electronic smoking devices, in addition to serving as “starter” products for the consumption of traditional cigarettes and vice versa the use of other drugs, makes ESDs an alarming problem for public health, despite being considered as a less harmful means of smoking (Kennedy et. al., 2019).
A study by Bertoni et. al., 2021 found that a higher prevalence of e-cigarette users was associated with males (3.26%), in the 18-34 age group, with 9 years or more of schooling (3.02%) compared to those in the younger age group, with 0.6%. It was also estimated that 6.86% of smokers use ESDs, and the Midwest region had the highest rate of users (11.59%), with the Federal District having 12.81%. One parameter that should be noted is that the majority were single and did not work.
The safe use of ECs (Electronic Cigarettes) with the release of nicotine has not been proven to be safe for the user’s health. The biggest problem is related to the lack of supervision and necessary regulations regarding the composition of the devices and the amount of nicotine available, whose values above 6 and 24 mg are more likely to cause some problems such as: exogenous intoxication, especially in vulnerable groups such as children, the elderly, pregnant women, nursing mothers and people with heart disease (World Health Organization, 2017, Leite et al., 2023; Sousa S et. al., 2023, Frazão et. al., 2023).
Isolated from the tobacco plant, nicotine is a natural alkaloid that quickly diffuses into the bloodstream when inhaled by humans, crossing the blood-brain barrier and reaching the central nervous system (CNS), where it will act as a stimulant (Elsa GG. et al., 2022). In the liver, nicotine is metabolized by the cytochrome P450 enzymes CYP2A6 and CYP2B6, forming various other biotransformation products. Most of these products will be converted into cotinine which is excreted through the urine (Elsa GG. et al., 2022, Wagner, Chen, Vrdoljak et al., 2020).
When inhaling smoke from electronic cigarettes, the user exposes their body to various microparticles of toxic products, causing damage to their health, especially when taking into account the respiratory system, which is the region that suffers most from the harmful effect generated by the smoke. The damage to the epithelium, the aggression to the replenishment of cells and the integrity of intracellular contacts generate various damages to the respiratory barrier (Galo et al., 2020, Werner et al., 2020, Vieira et al., 2024, Moura et al., 2024).
The damage to lung function, as well as the decrease in immunity, may be related to constant exposure to e-cigarette vapor, generating an increase in symptoms such as airway inflammation, oxidative stress and risk of respiratory infection. Given these symptoms, it is possible to notice the individual’s susceptibility to lung diseases, including pneumonia, COVID-19 and asthma (Galo et al., 2020, Moura et al., 2024, Bachur et al., 2024).
Electronic cigarettes have also been linked to Electronic Cigarette Associated Lung Injury (EVALI), characterized by the presence of symptoms within 90 days of starting to use electronic devices (Aldy et al., 2020). Other diseases have been described such as: acute eosinophilic pneumonia, diffuse alveolar hemorrhage, lipoid pneumonia, interstitial lung disease due to respiratory bronchiolitis (Werner, et al, 2020).
In 2019, EVALI (Electronic Cigarette Associated Lung Injury) was responsible for around 2,758 hospitalizations and 64 deaths in the United States (Aldy et al., 2020). In a study by DOUKAS et. al., 2020, 80% of patients had respiratory complaints such as cough, shortness of breath and pleuritic pain, 60% had gastrointestinal symptoms such as nausea, vomiting, abdominal pain, 70% reported symptoms such as: fever, fatigue and generalized weakness. Products containing tetrahydrocannabinol (THC) have been identified as the main cause of respiratory endothelial disease, as they cause a change in the surfactant’s gelatinous aspect to a crystalline liquid, leading to a loss of the surfactant’s surface tension capacity (Doukas et al., 2020).
Patients are increasingly seeking health centers as their clinical condition worsens, with respiratory and gastrointestinal symptoms such as nausea, vomiting, diarrhea, abdominal pain, chest pain, cough and shortness of breath, similar to those of pneumonia and severe sepsis. The criterion of infectious etiology is important in emergency medical cases and has helped to exclude other pathologies that may present similar symptoms (Aldy et al., 2020, Kligerman, et al., 2021, Heinzerling, et al., 2020, Bachur et al., 2024, Moura et al., 2024, Vieira et al., 2024).
When we consider cases of COVID-19, the symptoms can overlap with those of EVALI (Electronic Cigarette Associated Lung Injury), thus highlighting the importance of a study that can show similarities between the lung of a patient affected by COVID-19 and one with EVALI. It is possible to notice some differences. A CT scan of COVID-19 shows ground-glass opacity, a peripheral and subpleural distribution, multitubular involvement and a slightly lower lung predominance. In cases of EVALI, it is possible to characterize it as eosinophilic pneumonia, the subtype of pneumonia being the differential diagnosis of COVID-19 (Galo et al., 2020).
Treatment consists of abstinence from vaping (electronic cigarette) as a way of ensuring patient improvement. In addition, short-term corticosteroids can be administered, however, there are no clear guidelines regarding dosage and treatment time. With regard to the length of pharmacological treatment, some studies have shown that the patient’s condition improved within two weeks, with a similar period recommended for eosinophilic pneumonia (Kaous et al., 2020, De Oliveira et al., 2019, Chen et al., 2020, Jiang, et al., 2020).
In relation to cardiovascular diseases, a recent study by Bhatt et. al., 2017, concluded that both occasional and daily consumption of electronic cigarettes is associated with an increased risk of acute myocardial infarction, even after adjusting for concomitant consumption of conventional cigarettes (OR 2.25 – daily consumption; OR 1.99 – occasional consumption). E-cigarette use had a similar effect to conventional cigarette use on the risk of myocardial infarction. In this same study, the combined use of conventional and electronic cigarettes had a worse outcome than the isolated use of either form. Another study by Alzahrani et al., 2018 had already shown that daily e-cigarette consumption is associated with an increased risk of heart attack.
E-cigarettes therefore expose the body to a variety of chemical elements generated in different ways. One is generated by the device itself (metal nanoparticles) and the other is directly related to the heating or vaporization process. Thus, some products contained in the vapor of electronic cigarettes include carcinogens and cytotoxic substances, potentially causing lung and cardiovascular diseases, among others (INCA, 2021).
CONCLUSION
E-cigarettes are capable of changing the user’s smoking habit to conventional cigarettes, but they don’t interfere or do little to help smoking cessation. They also contain many toxic components that are directly related to the development of various diseases, especially respiratory and heart diseases, as well as exacerbating pre-existing diseases. It is therefore clear that the use of electronic cigarettes is harmful both to the user and to public health, and that more and more regulations are needed to monitor the dissemination of advertisements and the marketing of the product. It is suggested that further research be carried out to corroborate the harmful effects of e-cigarette use, understand its different aspects and devise strategies to reduce its effects, with a view to improving the health of the population in general.
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