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  • Why Vaping Is More Dangerous Than Cigarette Smoking And Why We Must Act Now

    Introduction

    Vaping was once promoted as a safer alternative to smoking. However, emerging evidence indicates that electronic cigarettes (e-cigarettes) may pose equal or even greater health risks compared to traditional cigarettes, particularly among youth. Unlike conventional tobacco products, vape liquids often contain a complex mix of chemicals, heavy metals, and flavouring agents that can bypass detection and regulation. Their sleek designs, enticing flavours, and the misconception of being “less harmful” have made vapes a gateway to nicotine addiction for a new generation.

    In Malaysia, the removal of nicotine from the Poisons Act in 2021 created a legal loophole that allowed unregulated vape products to proliferate. Although the Control of Smoking Products for Public Health Act 2024 was gazetted to address this issue, enforcement remains challenging. The health costs of inaction are escalating and may soon surpass the damages caused by traditional cigarettes.

    What Makes Vaping More Dangerous Than Cigarettes

    1. Rapid Uptake Among Youth and Stronger Addiction

    Vapes appeal to adolescents with thousands of flavours, sleek devices, and a strong presence on social media platforms. Many vape products contain higher nicotine concentrations than traditional cigarettes, delivered via nicotine salts that are more readily absorbed and less irritating, enabling deeper and longer inhalation (Benowitz & Fraiman, 2022).

    In Malaysia, data from the National Health and Morbidity Survey (NHMS) 2022 indicated that 14.9% of adolescents aged 13–17 were current e-cigarette users, with a higher prevalence among males (23.3%) compared to females (6.2%) (Institute for Public Health, 2022). Alarmingly, nearly half of these users initiated vaping before the age of 14.

    2. Exposure to Unregulated Chemicals and Aerosolised Toxins

    While cigarettes have known contents, vapes deliver poorly characterised chemical cocktails. Scientific studies have identified harmful substances in vape aerosols, including formaldehyde, acrolein, lead, cadmium, and nickel. These compounds can cause DNA damage, inflammation, and systemic toxicity (Olmedo et al., 2018).

    Additionally, some compounds in vape aerosols, such as vitamin E acetate and benzyl alcohol, have no history of safe inhalation use and have been implicated in severe lung injuries.

    3. Acute Lung Injuries Not Observed in Cigarette Smokers

    Traditional cigarette smoking is associated with chronic lung diseases developing over the years. In contrast, vaping has been linked to acute, life-threatening lung injuries, such as E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI), occurring after weeks or months of use. Patients suffer respiratory failure requiring ventilation, and some have died (Chand et al., 2023). Such rapid-onset pulmonary toxicity is virtually unheard of with cigarette smoking.

    4. Systemic Health Effects Beyond the Respiratory System

    Vaping has demonstrated harmful effects across multiple organ systems, including the gastrointestinal tract, brain, oral cavity, kidneys, and reproductive system. Studies indicate that vaping alters brain structure and impairs memory, attention, and mood, especially in adolescents (Lopez-Ojeda & Hurley, 2024). Animal models have shown that vaping disrupts intestinal barriers and triggers inflammation (Sharma et al., 2022).

    5. Increased Risk of Smoking Initiation and Dual Use

    Rather than replacing cigarettes, vapes are creating a new generation of dual users, individuals who smoke and vape. Adolescents who vape are more than three times as likely to start smoking cigarettes (Soneji et al., 2017). This trend undermines the potential harm reduction benefits of vaping and perpetuates nicotine addiction.

    6. Unproven Efficacy as a Smoking Cessation Tool

    While some trials suggest that nicotine-containing e-cigarettes may aid smoking cessation, real-world studies show mixed results. A Cochrane review noted low certainty of evidence for sustained cessation and highlighted a high risk of relapse and dual use (Hartmann-Boyce et al., 2022). Most adult vapers do not quit smoking; instead, they continue using both products.

    7. Environmental and Secondhand Exposure Risks

    E-cigarette waste, including cartridges, pods, and lithium batteries, contributes to environmental pollution. Aerosol residues accumulate on indoor surfaces, exposing non-users, especially children and pregnant women, to passive vaping. The World Health Organisation has declared secondhand exposure to e-cigarette aerosol unsafe (Jankowski et al., 2019).

    Conclusion

    Scientific evidence confirms that vaping poses serious health risks across the respiratory, cardiovascular, neurological, and gastrointestinal systems. Youth are disproportionately affected, and the claimed benefits of vaping, especially for smoking cessation, are not supported by strong data. Enforcement difficulties undermine regulatory measures, and the mounting health and environmental consequences are a concern. A comprehensive ban on vape products is a necessary and urgent public health action.

    References
    • Benowitz, N. L., & Fraiman, J. B. (2022). Clinical pharmacology of electronic nicotine delivery systems (ENDS): Implications for benefits and risks in the promotion of smoking cessation. Journal of Clinical Pharmacology, 62(1), 1–14. https://doi.org/10.1002/jcph.1982
    • Chand, H. S., Muthumalage, T., Maziak, W., & Rahman, I. (2023). Pulmonary toxicity and the pathophysiology of electronic cigarette, or vaping product, use associated lung injury. Annals of the American Thoracic Society, 20(2), 177–185. https://doi.org/10.1513/AnnalsATS.202209-796ST
    • Hartmann-Boyce, J., McRobbie, H., Lindson, N., Bullen, C., Begh, R., Theodoulou, A., Notley, C., Rigotti, N. A., Turner, T., Butler, A. R., & Hajek, P. (2022). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, (11). https://doi.org/10.1002/14651858.CD010216.pub7
    • Institute for Public Health. (2022). National Health and Morbidity Survey (NHMS) 2022: Adolescent Health Survey Highlights. https://iku.gov.my/images/nhms-2022/Report_Malaysia_nhms_ahs_2022.pdf
    • Jankowski, M., Brożek, G., Lawson, J., Skoczyński, S., & Zejda, J. E. (2019). E-cigarettes are more addictive than traditional cigarettes—A study in highly educated young people. International Journal of Environmental Research and Public Health, 16(13), 2279. https://doi.org/10.3390/ijerph16132279
    • Lopez-Ojeda, W., & Hurley, R. A. (2024). Vaping and the brain: Effects of electronic cigarettes and e-liquid substances. The Journal of Neuropsychiatry and Clinical Neurosciences, 36(1), A41–A45. https://doi.org/10.1176/appi.neuropsych.20230184
    • Olmedo, P., Goessler, W., Tanda, S., Grau-Perez, M., Jarmul, S., Aherrera, A., Chen, R., Hilpert, M., Cohen, J. E., Navas-Acien, A., & Rule, A. M. (2018). Metal concentrations in e-cigarette liquid and aerosol samples: The contribution of metallic coils. Environmental Health Perspectives, 126(2), 027010. https://doi.org/10.1289/EHP2175
    • Sharma, A., Lee, J. S., & Dela Cruz, C. S. (2022). E-cigarettes compromise the gut barrier and trigger inflammation. iScience, 25(2), 103818. https://doi.org/10.1016/j.isci.2021.103818
    • Soneji, S., Barrington-Trimis, J. L., Wills, T. A., Leventhal, A. M., Unger, J. B., Gibson, L. A., Yang, J., Primack, B. A., Andrews, J. A., Miech, R. A., Spindle, T. R., Dick, D. M., Eissenberg, T., Hornik, R. C., Dang, R., & Sargent, J. D. (2017). Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatrics, 171(8), 788–797. https://doi.org/10.1001/jamapediatrics.2017.1488

  • E-cigarettes as a Harm Reduction Strategy

    Introduction

    Amid growing concerns about long-term health impacts and youth uptake, over 33 countries, including Brazil, India, and Singapore, have instituted complete bans on e-cigarettes and vaping products. These bans underscore health concerns, especially regarding potential harms and unknown long-term effects (Ecigator, 2024; Statista, 2024; Global Issues, 2024). In contrast, around 87 nations regulate vaping through age restrictions, advertising bans, and usage limitations to control accessibility, especially among minors (Global Issues, 2024).

    Some countries, such as the United Kingdom, allow e-cigarettes as part of a harm reduction strategy, permitting regulated access to encourage adult smokers to transition away from traditional cigarettes. Australia has adopted a more conservative approach, requiring a prescription for e-cigarette access to balance harm reduction with health safety (Hawai‘i Public Health Institute, 2024). This global disparity highlights the ongoing debate surrounding vaping’s public health role, weighing its potential as a harm reduction tool against addiction risks and youth appeal. This article evaluates e-cigarettes using four established harm reduction criteria—reduction in harm, proven safety, efficacy, and accessibility—to determine whether they align with harm reduction standards.

    Harm Reduction Criteria

    For a product to qualify as a harm reduction tool, it must meet several key principles: demonstrate a reduction in health risks, provide conclusive evidence of short- and long-term safety, show effectiveness in reducing or eliminating harmful behaviours, and ensure accessibility without unintended consequences. This framework forms the basis for evaluating e-cigarettes as a harm reduction strategy.

    Reduction in Harm

    Harm reduction tools are intended to lower health risks significantly compared to current harmful behaviours. For e-cigarettes, this means offering a lower risk profile than traditional smoking. Public Health England estimates that e-cigarettes are “95% less harmful than smoking” due to the absence of combustion, which is the source of many toxic chemicals in cigarette smoke (McNeill et al., 2015). Studies indicate that e-cigarette vapour contains fewer carcinogens and toxic compounds than cigarette smoke, potentially reducing respiratory and cardiovascular risks (Glantz & Bareham, 2018).

    However, e-cigarette vapour includes harmful substances such as formaldehyde and volatile organic compounds, and regular use has been associated with a 30% increased risk of respiratory issues like asthma and COPD (Bhatta & Glantz, 2020). The reduction in harm is further complicated by limited long-term data, leaving the full health impact uncertain. While e-cigarettes may reduce exposure to certain toxins, their overall health implications remain unclear, meeting this criterion only partially.

    Proven Safety

    Safety is fundamental for any harm reduction strategy, requiring thorough evaluation for short- and long-term impacts to avoid introducing new health risks. Current evidence on e-cigarette safety is limited due to their recent introduction, with most studies focusing on short-term effects. Research has raised concerns about increased cardiovascular and respiratory risks; for example, e-cigarette users have been found to have a 56% higher risk of myocardial infarction than non-users, underscoring cardiovascular safety concerns (Bhatta & Glantz, 2020).

    The history of tobacco emphasises the risks of adopting products without robust safety data. Although tobacco use dates back to 6000 BCE, its addictive and harmful properties were not widely recognised until the 16th century. Cigarettes were marketed as safe until serious health risks were confirmed in the 1950s, nearly a century after their mass production began. E-cigarettes, similarly promoted as safer alternatives without long-term data, risk repeating this historical error. Without comprehensive long-term data, e-cigarettes do not meet the safety criterion.

    Efficacy

    Harm reduction strategies should be effective in reducing or eliminating harmful behaviour. Some studies suggest that e-cigarettes may assist smokers who struggle with traditional cessation methods. A trial by Hajek et al. (2019) found e-cigarettes to be nearly twice as effective as nicotine replacement therapy (NRT) when combined with behavioural support. Furthermore, widespread e-cigarette use could potentially prevent over 6.6 million premature deaths among American smokers (Levy et al., 2017).

    However, “dual use” — when individuals continue to smoke while using e-cigarettes — raises concerns, as it can increase overall nicotine exposure, potentially offsetting some of the harm reduction benefits. Evidence on long-term cessation is mixed, with some users returning to smoking or maintaining an e-cigarette dependency (Hartmann-Boyce et al., 2016). While e-cigarettes may offer a transitional tool for some smokers, dual use and sustained dependency challenge their efficacy as a full harm reduction strategy, meeting this criterion only partially.

    Accessibility and Acceptability

    A harm reduction tool should be widely accessible and acceptable to those who may benefit from it. E-cigarettes are widely available in numerous countries, accessible through online platforms and retail outlets. Their popularity, particularly among younger users, is often attributed to diverse flavours and appealing designs. In the UK, approximately 3.6 million adults reported using e-cigarettes in 2021, demonstrating significant accessibility and acceptance (ONS, 2021).

    However, the popularity of e-cigarettes among youth raises ethical concerns. In the United States, vaping among high school students surged from 1.5% in 2011 to 27.5% in 2019, driven by flavoured products and youth-oriented marketing (Cullen et al., 2018). This trend complicates the harm reduction goal, as increased nicotine addiction among youth poses a new public health risk. While e-cigarettes meet the accessibility criterion, ethical concerns about youth uptake remain significant.

    Conclusion

    Evaluating e-cigarettes against harm reduction criteria reveals only partial compliance. While e-cigarettes may reduce exposure to certain toxins compared to smoking, they lack conclusive long-term safety data and show mixed efficacy, especially given the potential for dual use. Although they are accessible and popular, especially among youth, this appeal introduces ethical challenges and potential health risks.

    The history of tobacco illustrates the risks of endorsing products without sufficient safety evidence. Healthcare professionals should avoid repeating these mistakes by endorsing e-cigarettes as a harm reduction tool prematurely. High standards of evidence are essential to protect public health and ensure that harm reduction strategies genuinely benefit those in need.

    Disclaimer: This article was drafted with the assistance of ChatGPT for research synthesis and writing. All information included is derived from reputable sources and cited in APA format.

    References

    Bhatta, D. N., & Glantz, S. A. (2020). Electronic cigarette use and myocardial infarction among adults in the US population assessment of tobacco and health. Journal of the American Heart Association, 8(12), e012317. https://doi.org/10.1161/JAHA.119.012317

    Cullen, K. A., Ambrose, B. K., Gentzke, A. S., Apelberg, B. J., Jamal, A., & King, B. A. (2018). Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018. MMWR Morbidity and Mortality Weekly Report, 67(45), 1276–1277. https://doi.org/10.15585/mmwr.mm6745a5

    Ecigator. (2024). Overview of vaping regulations by country. Ecigator. Retrieved from https://www.ecigator.com/vaping-regulations-country/

    Glantz, S. A., & Bareham, D. W. (2018). E-cigarettes: Use, effects on smoking, risks, and policy implications. Annual Review of Public Health, 39, 215–235. https://doi.org/10.1146/annurev-publhealth-040617-013757

    Global Issues. (2024). Ban or restrict? Quandary facing governments as vaping entices teens worldwide. Global Issues. Retrieved from https://www.globalissues.org/

    Hajek, P., Phillips-Waller, A., Przulj, D., Pesola, F., Myers Smith, K., Bisal, N., … & McRobbie, H. J. (2019). A randomised trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine, 380(7), 629–637. https://doi.org/10.1056/NEJMoa1808779

    Hawai‘i Public Health Institute. (2024). The countries where vaping is illegal, banned or restricted. Hawai‘i Public Health Institute. Retrieved from https://www.hiphi.org/

    Hartmann-Boyce, J., McRobbie, H., Bullen, C., Begh, R., Stead, L. F., & Hajek, P. (2016). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, (9). https://doi.org/10.1002/14651858.CD010216.pub3

    Levy, D. T., Borland, R., Lindblom, E. N., Goniewicz, M. L., Meza, R., Holford, T. R., … & Warner, K. E. (2017). Potential deaths averted in the USA by replacing cigarettes with e-cigarettes. Tobacco Control, 27(1), 18–25. https://doi.org/10.1136/tobaccocontrol-2017-053759

    McNeill, A., Brose, L. S., Calder, R., Hitchman, S. C., Hajek, P., & McRobbie, H. (2015). E-cigarettes