E-cigarette complications and consequences

˝If you‘ve never smoked or used other tobacco products or e-cigarettes, don‘t start.˝

The e-cigarette is not the once-promised panacea to traditional cigarettes, and, in fact, is creating a new set of risks we‘re watching closely. Here‘s the topline summary of the latest information. For more, see Lifting the e-cigarette smokescreen.

This advice is one constant in an evolving and escalating e-cigarette trend that has most recently spawned a mysterious rise in e-cigarette related lung illness with at least 37 confirmed deaths.

The e-cigarette is not the once-promised panacea to traditional cigarettes, and, in fact, is creating a new set of risks, we‘re watching closely.

Here are some key facts

  • There are approximately 1.1bn smokers in the world, and nearly 50 million vapers – 5 times the number in 2012.
  • Today's global e-cigarette market is estimated to be worth $19.3nb.
  • The top 5 countries that generate revenue from e-cigarette sales are US, UK, France, Germany and China.
  • Some countries (UK) more actively regulate e-cigarettes and limit the amount of nicotine they contain. The US does not.
  • Most e-cigarettes contain more nicotine than traditional cigarettes, and hence "trying them" inevitably leads to long-term addiction and use.
  • As of October 29, 2019, there have been 37 deaths confirmed as a result of e-cigarette use compared to 480,000 deaths from cigarette use annually across the US.
The youth e-cigarette epidemic continues to be a longer-term concern regarding our future policyholders and portfolios.

New Developments

Youth e-cigarette use still picking up steam

The rates of US high-schoolers who are vaping continues to increase alarmingly. A recent NEJM article notes 5.2‒6.4% increase in adolescent nicotine e-cigarette use (past 12 months) compared to 2018. Additionally, 40% of 12th graders have tried an e-cigarette. The idea that it is “safe”, cool, easily hidden, and contains teen-friendly flavours such as bubble gum, continues to create a future wave of nicotine addicts who at best might be long-term e-cigarette  users, and at worst may shift to traditional combustible cigarettes.

Respiratory disease and deaths on the rise

As of October 29, 2019, 1888 cases of patients admitted with respiratory distress related to e-cigarettes have been reported to the Centers for Disease Control (CDC) from 49 states, the District of Columbia and one US territory. This also includes 37 deaths. Most (86%) admit to using THC containing products. Others (11%) report exclusive use of nicotine-based products. There have been reports of “street sold” products containing vitamin E oil. One current view of the pathology related to the respiratory distress is linked to a lipoid (or fatty deposit) type of pneumonia, ostensibly from the added oils in THC or unregulated manufacturing, although other studies suggest  a chemical pneumonitis, which could be due to an inhaled toxin.

Cancer causing?

A recent study found mice exposed to e-cigarette smoke have increased incidence of lung cancer and bladder hyperplasia. Vaporised nicotine-containing e-cigarette smoke in this study was associated with increased lung cancer in mice, but previous rat studies showed no correlation to cancer with two years of nicotine exposure. The authors state that while it cannot be translated to human harm, further studies are warranted.

Heated tobacco products

These tobacco products are not combusted but heat tobacco electromechanically to release nicotine and tobacco flavours. Although studies indicate significantly reduced levels of the typical harmful and potentially harmful ingredients in traditional cigarettes, there are additional chemicals released. The FDA has concluded that one of these products, IQOS made by Philip Morris International (PMI), lacks necessary long-term data, and cannot be deemed a “reduced risk” tobacco product. There are more than 11 million users of IQOS globally.

What’s inside an e-cigarette?

There are two main systems, open and closed. Open systems allow for the addition of any vaping liquid or adulterant, hence is susceptible to contamination  and irregular or unregulated  manufacturing. The “closed” products tend to be made by big tobacco companies and are less exposed to tampering or adding adulterants as with open e-cigarettes.

E-cigarettes’ main constituents are propylene glycol, glycerin, flavourings and nicotine. Glycol and glycerin are considered relatively harmless, and hence vaporised nicotine and the flavourings are areas of study as are other added chemicals. Some studies show certain flavourings are more harmful than others. Mint and menthol contain a known carcinogen, pulegone, which has been banned by the FDA as a food additive. Levels of pulegone in menthol and mint flavoured e-cigarettes are higher than in traditional menthol cigarettes, and below the 10000 (safety) margin of exposure level used by the FDA. Cinnamon flavored liquids have also been shown to be the most potent in terms of cytotoxicity when considering endothelial cell in-vitro studies. President Trump has indicated the FDA will ban almost all flavoured vaping products, and several states have recently banned flavoured e-cigarette products.

A pathway to quit or to double up?

A recent study showed e-cigarettes being twice as effective at achieving 12-month cessation compared to traditional nicotine replacement therapy. A 2014 study found 30% of e-cigarette users in the US are former smokers, but a large percentage of e-cigarette users continue to smoke traditional cigarettes, leading to so called “dual use”.

Nicotine addiction in developing brains on a mass scale is clearly undesirable and the future impact is still unknown.

An overview of the issues for insurers


Noting the inconclusive evidence on the long-term effects of e-cigarettes and the contradictory impacts of facilitating smoking cessation, versus creating a new pathway to use of tobacco and related products, Swiss Re adapts its approach according to different market environments. Depending on market developments, including cotinine testing as well as accuracy and contestability of underwriting disclosures, Swiss Re does see opportunities in some markets to develop further price differentiation with our clients based on usage of different types of e-cigarette products.


Issues to be aware of: Vaping anything but retail-sold e-cigarette products should raise concern, as adding any liquid purchased on the street or cannabis related oils (like THC) could lead to respiratory distress, disease and death. Using a closed system like Juul reduces the risk of using adulterants or poorly manufactured liquids. Disclosure remains a constant challenge. E-cigarette users who admit to using marijuana should also raise concern and it may be worth verifying that vaping of marijuana (THC) is not being performed.

Going forward

Swiss Re continues to monitor this space very closely and will update our clients directly if anything changes significantly. The CDC continues to state: “E-cigarettes have the potential to benefit adult smokers, if used as a complete substitute for regular cigarettes and other smoked tobacco products.” The youth e-cigarette epidemic continues to be a longer-term concern regarding our future policyholders and portfolios. Nicotine addiction in developing brains on a mass scale is clearly undesirable and the future impact is still unknown.

The FDA decided to delay the compulsory premarket review of new tobacco products (including e-cigarettes), but after a lawsuit by major health groups, a federal court recently ordered its implementation by May 2020. This will hopefully create a far more regulated market place in the US, with expected safer products for e-cigarette users.

E-cigarette complications and consequences

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