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Almost one million Brazilians regularly use e-cigarettes

Despite being banned in the country, the devices are used by many young people aged 18 to 34

Around 80% of the people who have consumed electronic cigarettes are between 18 and 34 years of age

Léo Ramos Chaves/Pesquisa FAPESP Magazine

On July 6, the Brazilian Health Regulatory Agency (ANVISA) maintained the prohibition on the importation and sale of electronic smoking devices (ESDs), better known as electronic cigarettes or vapes, in Brazil. The ban has been in place since 2009, but the devices are being sold on numerous websites in the country with prices starting at R$50, as well as by street sellers and even in physical stores. Electronic cigarette consumption is more frequent among young Brazilians, although still at lower levels than occurs in countries that have legalized the sale of the product to adults, such as the USA and the UK.

It is what was found in the study by epidemiologists Neilane Bertoni and André Szklo, from the National Cancer Institute (INCA), of Rio de Janeiro, published in July 2021 in the scientific journal Cadernos de Saúde Pública. The work analyzed the prevalence of ESD use in the 26 Brazilian state capitals and in the Federal District and verified that around 80% of the people who have consumed electronic cigarettes are between 18 and 34 years of age. “We observed that one in every five young adults from 18 to 24 years of age has already used these devices. Adults are not the target audience of the manufacturers. Additives with sweet flavors are put in the product to attract young people,” says Bertoni. “Among the individuals aged 35 or above, less than three in every 100 use electronic cigarettes.” In the US, lawmakers have tightened controls against the manufacturers with the aim of banning or restricting the offer of electronic cigarettes with candy or fruit flavors.

The researchers used data collected by the Brazilian Ministry of Health through the 2019 VIGITEL telephone survey (Surveillance System for Risk and Protective Factors for Chronic Diseases). They interviewed 52,443 individuals aged 18 or over. Based on these numbers, they estimate that 6.7% of adults in the state capitals have tried electronic cigarettes and 2.3% currently use the product in the country. In total, it is estimated that 2.4 million individuals have had contact with these devices and 835,000 smoke electronic cigarettes.

The USA accounts for at least one-third of revenue from the global electronic cigarette market, a sector set to generate around US$22 billion this year. Since 2014, the vape has become the preferred nicotine-based product among North-American students between 14 and 18 years of age, according to data from US Centers for Disease Control and Prevention (CDC). In the past two years, consumption among the country’s school students has started to fall in this age group, although it still remains at significant levels with over 2 million regular users. The most recent annual CDC study, conducted in 2021, about the use of tobacco among High School students, indicated that 11.3% of the students had used electronic cigarettes in the 30 days prior to the interview. In 2019, this rate represented 27.5% of the students and 19.6% in 2020.

As in studies carried out abroad, the study done by Bertoni and Szklo highlights a worrying detail: more than half of the individuals that have experimented ESDs had never previously smoked a conventional cigarette. The data indicates that electronic cigarettes could be a gateway to smoking for new generations of Brazilians. Besides being addictive, nicotine, the almost universal ingredient of electronic cigarettes, can affect the development of the brain, especially in adolescents. Not to mention the possible harm that the other components of the vapes may cause.

Alexandre Affonso

A systematic review article, made by another team of researchers from the INCA and published in December 2021 in the journal Ciência e Saúde Coletiva, confirms this risk. The study joins the results from 25 international studies conducted between 2015 and 2019 that assessed the association between using electronic cigarettes and starting to smoke. The result is worrying: using these devices increased the risk of trying conventional cigarettes by almost three-and-a-half times and of becoming a user of the traditional product by over four times.

“Electronic cigarettes started to be advertised abroad as an alternative for stopping conventional smoking, but they are being used in a recreational way,” says pulmonologist Felipe Marques, of the Hospital Beneficência Portuguesa of São Paulo, who attended one of the first suspected cases recorded in Brazil of a new lung disease associated with the use of electronic cigarettes called EVALI (see article).

Created in China in the 2000s, electronic cigarettes were advertised as a possibly less damaging alternative to smoking. As they do not involve burning tobacco, they do not produce smoke or release carbon monoxide and tar, two of the most harmful ingredients to health linked with conventional smoking. These devices come in different formats and can resemble a cigarette, a pen, a pen-drive, or a small tank (see illustration). The different generations of ESDs share a common feature, some single use, others rechargeable: all the devices have an internal battery to heat a fluid mixture stored within, and thus generating an aerosol—a cloud of particles suspended in air—similar to a gas or vapor.

It is estimated that 2.4 million Brazilians have already tried electronic cigarettes

The composition of the aerosol inhaled by the user comes from the ingredients used in these e-liquids, as the fluids are called, and varies depending on the version and manufacturer of the product. In general, the main ingredients are water, nicotine, vegetable glycerin, propylene glycol, and substances that provide a specific flavor to the electronic cigarette. There are also liquids that use cannabinoids (CBD and THC), substances derived from plants of the Cannabis genus, instead of nicotine. Although officially aimed at an adult audience, electronic cigarettes usually use sweetened flavorings, of fruits or candies, a bait that makes them more attractive to children and young adults.

“The term vapor is deceptive. The electronic cigarette doesn’t produce only water vapor, as it was initially advertised,” says pulmonologist Paula Corrêa, of the Federal University of Ouro Preto (UFOP) and coordinator of the Scientific Commission on Smoking of the Brazilian Society of Pulmonology and Phthisiology (SBPT). “Heating the liquid in the device produces an aerosol in which almost 2,000 substances have already been detected, many toxic and the majority unknown. Some of these additives, when inhaled, may cause irritation and acute lung damage.” Besides being a substance that causes addiction and dependence, nicotine increases blood pressure and causes surges of the hormone adrenalin, which can raise the heart rate. There are indications that the process of vaporizing the e-liquids itself may create toxic and carcinogenic substances.

Alexandre Affonso

Beyond the lung
It is not only the pulmonologists who are worried about the growing use of electronic cigarettes. A systematic review study published in the journal European Urology Oncology, in October 2021, joined 22 studies that identified 63 urinary biomarkers of several carcinogenic compounds linked to tumors of the bladder in higher concentrations among electronic cigarette users than in the control group.

Dentists are also already on alert with regards to the arrival of these electronic devices, which may affect the buccal mucosa and cause cellular anomalies—with the consequent risk of oral cancer—similar to those caused by conventional cigarettes. This is the main conclusion of an article published in April last year by the team of dentist Janete Dias Almeida, from the Biosciences and Buccal Diagnosis Department of São Paulo State University (UNESP), São José dos Campos campus.

In the work, published in the periodical Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology, buccal mucosa cells were compared in 91 volunteers split into four groups: 20 electronic cigarette smokers, 22 conventional cigarette smokers, 22 ex-smokers, and 27 nonsmokers. Different types of anomalies were found in the nucleus of mucosa cells from conventional and electronic cigarette smokers, in a significantly higher amount than in ex-smokers and nonsmokers. The study is one of the results of a research project by Almeida with funding from FAPESP. According to the researcher, the chemical substances resulting from the increased temperature of the liquids in these electronic devices, which surpass 300 degrees Celsius (ºC), may be responsible for the cellular damage in the mucous membranes of the users.

Researcher Sandra Farsky, from the School of Pharmaceutical Sciences of the University of São Paulo (FCF-USP), is studying the possible impacts of ESDs on rheumatoid arthritis in comparison to the effects of conventional cigarettes, a known risk factor for the appearance and progression of the disease. It is an experimental study, with mice, carried out in collaboration with the Center for Research in Inflammatory Diseases (CRID), one of the Research, Innovation, and Dissemination Centers (RIDCs) funded by FAPESP. After being chemically induced to present rheumatoid arthritis, the animals were exposed to conventional cigarette smoke and clouds of aerosols from the electronic devices.

After 20 days, both groups of rodents presented equivalent levels of nicotine in the blood, although the joint symptoms had worsened in the animals that had contact with smoke from burning tobacco. “We showed that exposure to ESDs does not worsen rheumatoid arthritis, which happens with cigarettes. This indicates that the toxic compounds that lead to the worsening of arthritis are released by burning tobacco,” explains Farksy. However, the ESDs harm the defense cells of the organism. “They cause immunosuppression in lymphocytes [a type of white blood cell], as occurs with exposure to conventional cigarettes, and harm the production of neutrophils [cells specialized in combating bacteria and fungi].” These first results of the partnership were published in the periodical Science of the Total Environment in February of this year.

Stephanie Keith / Getty Images Shelves in the USA with electronic cigarettes: attractive shapes and colorsStephanie Keith / Getty Images 

In this project, the FCF researcher chose to work specifically with HNBT electronic devices, which stands for heat-not-burn tobacco. In place of the e-liquid of the most widespread electronic cigarettes, a quantity of tobacco is loaded inside these stick-shaped devices. The tobacco is heated, but not burned, as occurs with conventional cigarettes. Instead of smoke from burning tobacco, a cloud of particles is generated to be inhaled by its user.

The HNBT manufacturers claim that it is less addictive as a result of not burning the tobacco and reaching temperatures of 360 °C, around half the heat created by a traditional cigarette. But it was not because of this supposedly lower toxicity that HNBTs were used in the study. “With these small sticks of heated tobacco, it is possible to have greater control of the amount of nicotine released by these devices,” the researcher clarifies. In the more common vapes, this management would be much more difficult, since they have different quantities of nicotine and there are even models that can be personalized by the smoker

The lack of control on the quantity and dose of the inhaled chemical products, starting with nicotine, the substance that creates the chemical dependence on smoking, is an additional risk for those who use the electronic devices. Even products sold as being nicotine free may present small concentrations of the substance. In an analysis published in 2017 in the American Journal of Public Health by CDC researchers, traces of nicotine were detected in products labeled as “zero nicotine.” In other devices, the actual concentrations of nicotine differed from those reported on their labels.

“Nobody smokes anything if there is no nicotine,” says Corrêa. This substance, derived from tobacco, acts on the mesolimbic dopaminergic system of the brain, associated with reward mechanisms. “It is a type of system created by the human organism to guarantee survival of the species, responsible for feeling pleasure when we eat, drink, have sex, or do physical exercise.” In the case of ESDs, the combination of propylene glycol and vegetable glycerin, two ingredients present in the majority of e-liquids, produces acetaldehyde, a substance that together with nicotine increases the potential for dependence on the product.

There is even an aggravating factor in the latest generation vapes: the substitution of pure nicotine with acidic nicotine salts. Produced by the association of nicotine with benzoic acid, the salts mask the harsh and bitter feeling in the throat caused by the nicotine. With this mixture, the electronic cigarette manufacturers make the product more palatable and able to contain more nicotine in the device. The quantity of nicotine in a pod—a little tank—with less than 1 milliliter of e-liquid of the brand Juul, market leader in the USA, is equivalent to a pack of 20 cigarettes.

Alexandre Affonso

Results from the majority of the latest research contradict the main selling point of the electronic devices, that have been advertised by the tobacco industry as a safer alternative to be used by those wanting to quit smoking or reduce the negative impact of the habit. Instead of using nicotine patches stuck to the skin, smokers are turning to electronic cigarettes.

Today, however, the story from the inventor of these devices himself, Chinese pharmacist Hon Lik, refutes this argument. In several interviews with the international press, Lik reports that in 2003 he created the first devices that produce aerosols by heating liquids containing nicotine in an attempt to find a way of quitting smoking. At the time, he was smoking three packs of cigarettes a day and had already lost his father, also a smoker, to lung cancer. Today, he uses both types of product, conventional and electronic cigarettes, but he says that he smokes cigarettes “just to check the flavors that he will use in the devices,” according to the British newspaper The Guardian. In 2013, Lik sold the patents of the electronic cigarette to Fontem Ventures, the Dutch subsidiary of Imperial Tobacco, from the UK, for US$75 million. Today he is a consultant for the company and continues to defend the use of these devices for adults who wish to quit smoking. “Personally, I think regulators should concentrate more on establishing age limits than banning flavors [for electronic cigarettes],” he said in August 2020, in material published on the Imperial Tobacco website.

835,000 people currently use vapes, according to the projection from the INCA

In England, the use of electronic cigarettes has been regulated since 2015 as an alternative pharmaceutical resource to nicotine patches for treating people over 18 years of age trying to quit smoking. Public Health England (PHE) considers the use of electronic cigarettes as less harmful to health than conventional cigarettes. A study published in 2019 in the periodical New England Journal of Medicine suggests that electronic cigarettes would be more effective than nicotine replacement therapy when accompanied by behavioral support.

The work randomly selected 886 individuals from a total of 2,045 clients of services that provide treatment for quitting smoking and monitored the results of the two approaches. One year after the start of the experiment, the rate of people not smoking was 18% in the electronic cigarette group and 9.9% for the nicotine replacement group, using patches, chewing gum, lozenges, or another form chosen by the patient. The study, one of the few with favorable results for the use of electronic cigarettes in programs for reducing smoking, was carried out with sponsorship from the National Institute for Health Research and from the Cancer Research UK Prevention Trials Unit.

Pulmonologist Paulo Corrêa, of UFOP, and epidemiologist Neilane Bertoni, of the INCA, disagree with the British strategy. They consider that allowing the sale of electronic cigarettes could represent a threat to the public health policies that have successfully fought smoking in Brazil over the past decades. Data from the INCA suggests that, in 1989, almost 35% of Brazilians were smokers of conventional cigarettes. In 2019, this rate was below 13%.

E-cigarettes: Cytodiagnosis and analysis of the metabolome and biophotonics of salivar (nº 20/10362-0); Grant Mechanism Regular Research Grant; Principal Investigator Janete Dias Almeida (UNESP); Investment R$132.894,82.
2. Effects on rheumatoid arthritis of exposure to heated tobacco vapor (nº 19/19573-7); Grant Mechanism Regular Research Grant; Principal Investigator: Sandra Farsky (USP); Investment R$248,217.23.

Scientific articles
HELUANY, C. S. et al. Toxic mechanisms of cigarette smoke and heat-not-burn tobacco vapor inhalation on rheumatoid arthritis. Science of the Total Environment. vol. 809. feb. 25, 2022.
BJURLIN, M. A. et al. Carcinogen biomarkers in the urine of electronic cigarette users and implications for the development of bladder cancer: A systematic review. European Urology Oncology. vol. 4, no. 5. oct. 2021.
BERTONI, N. & SZKLO, A. Dispositivos eletrônicos para fumar nas capitais brasileiras: Prevalência, perfil de uso e implicações para a Política Nacional de Controle do Tabaco. Cadernos de Saúde Pública. vol. 37, no. 7. 2021.
BARUFALDI, L. A. et al. Risco de iniciação ao tabagismo com o uso de cigarros eletrônicos: Revisão sistemática e meta-análise. Ciência & Saúde Coletiva. vol. 26, no. dec. 12, 2021.
SCHWARZMEIER, L. A. T. et al. E-cig might cause cell damage of oral mucosa. Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology. nov. 19, 2020.
HAJEK, P. et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine. feb. 14, 2019.
MARYNAK, K. L. et al. Sales of nicotine-containing electronic cigarette products: United States, 2015. American Journal of Public Health. vol. 107, no. 5, may 2017.