With technology advancing and almost everything that was once tangible turning electronic (see: e-mail, e-book, e-commerce), it’s no surprise cigarettes have also evolved into e-cigarettes — the smoking of which is known as vaping. According to the National Institute on Drug Abuse, vaping devices are now the most common form of nicotine among youth in the United States. Vaping devices are “battery-operated devices that people use to inhale an aerosol, which typically contains nicotine (though not always), flavorings, and other chemicals.” Vapes come in all shapes and sizes, resembling traditional tobacco cigarettes or everyday items like pens or USB sticks, meaning they are easy to hide in plain sight.
Is vaping as harmful as smoking cigarettes? And if so, why is it so heavily marketed to teens and youth? According to the U.S. Food and Drug Administration (FDA) in its 2022 Annual National Youth Tobacco Survey, 14.1% of high school students and 3.3% of middle school students reported current e-cigarette use.
With the onset of the COVID-19 pandemic, respiratory illnesses are currently a hot-button issue. A 2020 article from Stanford Medicine linked vaping to a substantially increased risk of COVID-19 among teenagers and young adults. In fact, surveying over 4,000 participants between the ages of 13 and 24 in all 50 U.S. states found that “those who vaped were five to seven times more likely to be infected than those who did not use e-cigarettes.” And participants who had used e-cigarettes at least once were five times more likely to be diagnosed with COVID-19. This is because of the damage vaping causes to the lungs and its related effect of suppressing the immune system, making it more difficult to fight off respiratory infections.
“Some of the major issues with vaping are that there are certain toxins that are present within the chemicals that come within the vaping system,” explains Dr. Faiz Bhora, chief of thoracic surgery and regional chairman of surgery for the central region of Hackensack Meridian Health (HMH). “At least one study has shown that you can get almost four times as much tar with vaping than you do with just smoking cigarettes.”
And he would know, as he’s seen his fair share of college students and young adults who have come in with collapsed lungs, or pneumothorax, following vaping. “You have to put in a drain in the chest if it’s the first time, [but] if it happens again, you usually need an operation to get [the lung] fixed,” says Bhora.
Surgeries to treat “vape lung” are a relatively new phenomenon, but Bhora has been working in thoracic surgery for more than 20 years. Upon entering medical school, his interest in this specialty was immediately piqued.“I was particularly fascinated by the anatomy and the physiology of the organs in the chest, the heart and lungs,” says Bhora. He was exposed to the medical world from a young age — his father was a cardiologist, and his mother was an OBGYN — so it’s no surprise that he ended up becoming a cardiothoracic surgeon. After attending medical school in Pakistan and doing his surgical residency at George Washington University in DC, he completed a cardiothoracic fellowship from the University of California, Los Angeles followed by an extra year of cancer surgery at the University of Pennsylvania.
Eventually, Bhora found his way to HMH in New Jersey, and is now the regional chairman of surgery for the central region of HMH, the chief of thoracic surgery and professor of surgery at the medical school. “I’m in charge of most of the surgical services, [and] I’m responsible for building programs for recruitment [to make] sure that we provide the highest quality of care for all the patients in our region.”
Bhora maintains this high quality of care for patients both young and old. Though his typical lung surgery patient is decades past young adulthood, within the last eight years or so, vaping-related illness or injury has brought more and more young people under his care. “The issue is that folks start vaping at a very young age,” says Bhora. “That inhalation of toxic chemicals and tar has a very detrimental effect on health.” The sense of invincibility common among teenagers — lending a devil-may-care attitude when it comes to their health — is not the only cause for vaping’s young demographic. There is also a heavy push from e-cigarette brands such as Puff Bar and JUUL to market their products to young users. A 2022 Bloomberg Law article accused JUUL of producing “calculated advertising campaigns [that] created a new generation of nicotine addicts.”
Connecticut Attorney General William Tong, in the Bloomberg Law article, describes the impact of JUUL’s youth marketing, noting how they “relentlessly marketed vaping products to underage youth, manipulated their chemical composition to be palatable to inexperienced users, employed an inadequate age verification process, and misled consumers about the nicotine content and addictiveness of its products.”
In an effort to halt teens and adults from purchasing vapes, in 2020, the FDA banned the sale of certain flavors that could be perceived as youth-friendly and only permitted the sale of flavors like tobacco and menthol. However, the ban failed to serve its purpose, with “less than 5% of the 3,500 adult e-cig users quitting [the use of] e-cigs in response to the flavored e-cig ban,” according to a 2020 University of Rochester article. “The rest of the respondents switched to other forms or flavors of e-cigs not covered by the ban or other types of tobacco products.”
In June 2022, the FDA banned JUUL products on US shelves, and the company agreed to pay millions of dollars in settlements to certain states over its unlawful targeting of underage consumers. However, less than two weeks after the ban was announced, it was lifted due to an appeal from JUUL. The FDA then announced a temporary stay on the ban to review additional information.
Negative effects in the short term may make some young people reconsider e-cigarette use, but health consequences that take time to develop are easier to ignore. “We all begin with the premise that [vaping] is harmful to your health,” says Bhora. “No matter how much you do, small or large, it’s still harmful. Obviously the more you do it, the more risks you have, but even a small amount on a regular basis will most likely lead to harming your lungs and perhaps increasing your risk of lung cancer.”
Bhora also explains symptoms to watch out for that could point to lung damage, with chronic cough and difficulty breathing being the most common. “Once you start getting symptoms, you may be a bit far along in terms of lung damage,” says Bhora. “That’s the problem with smoking and other respiratory toxins; once you actually have symptoms, the damage may already be set and in place.”
Even vape products without nicotine, such as “wellness vapes” or e-cigarettes that are touted to have vitamins, hormones, or essential oils, are not healthy for inhalation, explains Bhora, as introducing any foreign substance into the lungs can be harmful. “I can’t imagine that any of these [wellness vapes] are any better than a healthy lifestyle, eating healthy foods, moderate exercise, and staying away from things that are chemicals or potential toxins.”
The FDA also wants consumers to know that no vaping products have been approved to prevent or treat any health conditions or diseases, stating that claims from wellness vapes are “unproven, and the products may be ineffective, a waste of money, unsafe and may prevent or delay you from seeking an appropriate diagnosis and treatment from a health care professional.” Inhaling products can also be dangerous and can trigger severe coughing, airway tightening and make speech and breathing difficult.
Bhora advises that all youth and young adults be cautious about using any vape or recreational drug, from marijuana to alcohol to nicotine, because of the potential for these to be “gateway drugs,” or drugs that may lead to the use of other addictive drugs.
As for his work, Bhora is looking forward to continuing to serve patients and spreading awareness about the dangers of vaping and other scenarios that can contribute to lung damage. His goal is to make JFK University Medical Center at HMH a flagship hospital, not just for the region, but for the state and beyond. Patients are already coming from New York City and Connecticut for operations, which Bhora hopes will make HMH a destination hospital with some of the most complex operations being performed there.
The hope is that more patients from other areas will receive the quality of care HMH provides, whatever operation they may need. “I think it’s really exciting to work at HMH,” says Bhora. “They’re the largest health system here in New Jersey, [they have] a new medical school, a great research institute in the Center for Discovery and Innovation, and [they are] committed to providing the highest quality of care for patients.”