Rising trend of E-cigarettes among adolescents of Pakistan and cardiovascular implications of electronic nicotine delivery systems

Abstract

It is a common misconception that e-cigarettes are safer than tobacco smoking, given their adverse cardiopulmonary effects, habituation, and the fact that it is only a fashion based manifestation to sell and use them. Therefore, the use of e cigarettes should not be encouraged as an alternative and pragmatic measure should be taken to profess this agenda.

Key Words: Adolescents; Cardiovascular implications; E-cigarettes; Nicotine

Core Tip: E-cigarette use among adolescents in Pakistan is rising rapidly, driven by misconceptions of safety and lax regulations. This trend poses serious cardiovascular risks due to nicotine, aldehydes, and toxic particles that induce inflammation, oxidative stress, and vascular dysfunction. Urgent public health measures are needed to curb use and prevent long-term cardiovascular harm.

INTRODUCTION

The prevalence of e-cigarette use among Pakistani teenagers has become a source of rising worry due to the possible cardiovascular consequences. E-cigarettes, also known as electronic nicotine delivery systems (ENDS), have gained popularity globally, notably among young people in Pakistan[1]. Adolescents in Pakistan are increasingly turning to e-cigarettes, driven by certain reasons such as ease of access, aggressive marketing, and beliefs of lower damage compared to traditional tobacco products. However, the systemic effects especially the cardiovascular risks of e-cigarettes remain a major source of enigma and fretfulness. While conventional tobacco smoking is widely known as a risk factor for cardiovascular disease (CVD), cardiovascular effects of e-cigarette usage among Pakistani teenagers are not well recognized. This knowledge gap emphasizes the necessity for extensive study to investigate the cardiovascular consequences of e-cigarettes in this cohort[2-5].

The existing literature on e-cigarette usage and its cardiovascular repercussions is primarily based on studies undertaken in Western nations, with little study relevant to Pakistan. These findings, however, may not be completely applicable to the Pakistani teenage population due to cultural, environmental, and genetic variations. Thus, there is a significant need for localized research to clarify the cardiovascular consequences of e-cigarettes among teenagers in Pakistan[2,3,6]. Despite the increasing prevalence of e-cigarette use among Pakistani teenagers, there is an extensive gap in research on the cardiovascular consequences of this development. Existing research focuses mostly on Western populations, and there is no information on the particular cardiovascular consequences of e-cigarettes among Pakistani teenagers. Furthermore, the possible linkages between e-cigarette usage and other cardiovascular risk factors common in Pakistan, such as air pollution and dietary patterns, are unknown. Bridging this research gap is critical for informing public health policies and treatments targeted at reducing the cardiovascular hazards associated with e-cigarette use among Pakistan's adolescents[7].

BIOCHEMISTRY OF E-CIGARETTES

E-cigarette aerosols are characterized by a complex mixture of gases and particles that are influenced by a variety of elements such as the e-liquid's unique formulation, how it is puffed, and the device's operational parameters. The major aerosols emitted by an e-cigarette are composed primarily of propylene glycol, vegetable glycerin, ethylene glycol, 1,3-propanediol, and 1,2-propanediol, as well as a varying amount of nicotine. Experiments have identified thujon, ethyl vanillin, coumarin, camphor, safrole, menthol, and acetaldehydes as flavoring compounds[7-9].

E-cigarettes, also known as ENDS, are a diverse and perpetually expanding product category. Variability in physical parameters, such as tank style, battery power, and temperature settings, can have a substantial impact on vapor production. E-liquids are amalgamates of nicotine, flavorings, and carrier chemical substances. While some studies have discovered trace quantities of potential toxicants in both e-cigarette liquids and vapor, the extent of real human exposure remains comparatively underexplored compared to conventional cigarette smoking, which is believed to be around one-quarter as widespread[10,11].

RISING TRENDS OF E-CIGARETTES IN PAKISTAN

The worldwide e-cigarette and vape industry was valued at $22.45 billion in 2022 and is expected to rise significantly between 2023 and 2030, with a compound annual growth rate of 30.6%. This upsurge is especially noticeable in Western markets and Southeast Asian nations like as Bangladesh, Nepal, India, and, most importantly, Pakistan, which is quickly establishing itself as a major participant in the vaping business. Pakistan's e-cigarette income is expected to reach $77.2 million by 2024, with a 1.39% annual growth rate. Another study highlighted that 50.4% of students in colleges and universities had tried vaping, with 41.9% using e-cigarettes daily[12].

For several years, Pakistan has seen a steady increase in the popularity of vaping. A study carried out in Karachi in 2017 by medical students indicated that many consumers were using vaping devices without fully comprehending their contents and related health hazards. Unfortunately, a similar pattern appears to be occurring right now, implying that vaping might possibly turn into an epidemic in Pakistan before the negative impacts are completely understood[12]. The comparatively liberal restrictions governing vaping, including its use, advertising, promotional activities, sponsorship, and packaging, have made vaping more accessible to a more widespread population in Pakistan. Also, the availability of flavored e-liquids heightens its appeal, particularly among the youth, who are the major target demographic. Factors such as peer influence, the lack of societal shame, and ease of availability all contribute to its appeal among youth. This offers a challenging problem for Pakistan as it navigates economic challenges such as high inflation while also tackling the growing issue of vaping, which necessitates a balanced strategy that takes into account both public health concerns and economic factors[12].

CARDIOVASCULAR IMPLICATIONS: MECHANISMS, BIOMARKERS, AND LONG-TERM CONSEQUENCES

Nicotine, the primary addictive agent in e-cigarettes, contributes significantly to cardiovascular risk. It induces endothelial dysfunction, increases heart rate, blood pressure, and coronary resistance, and promotes atherosclerosis[13]. Carbonyl compounds like formaldehyde, acetaldehyde, and acrolein found in e-cigarette aerosols contribute to oxidative stress, vascular inflammation, and autonomic imbalance, further exacerbating cardiovascular risk[14,15]. Animal studies corroborate these effects, highlighting increased blood pressure, arrhythmias, and potential cardiac damage from chronic exposure to these substances[15]. Furthermore, ultrafine particles in EC aerosols can penetrate the circulatory system, potentially causing endothelial injury and accelerating cardiovascular pathologies[16]. Research has also indicated that chronic e-cigarette use may impair vascular reactivity, leading to arterial stiffness and impaired nitric oxide bioavailability, which are critical markers of cardiovascular dysfunction[17]. Additionally, biomarkers such as C-reactive protein, interleukin-6, and tumor necrosis factor-alpha have shown elevated levels in e-cigarette users, further affirming an inflammatory profile that supports the development of CVDs[18]. These effects are particularly concerning in adolescents whose cardiovascular systems are still in development, making them more vulnerable to long-term damage. Evidence also suggests that dual use of e-cigarettes and conventional cigarettes amplifies cardiovascular risk through cumulative toxic exposure and compounded oxidative stress[19]. Therefore, the cardiovascular threat posed by e-cigarettes among adolescents warrants urgent attention and preventive public health strategies.

MEASURES OF PREVENTION

Overall, while e-cigarettes may be less harmful than conventional cigarettes, they are not completely safe and can have negative health effects[20]. The non-linear dose-response relationship between smoking and cardiovascular mortality suggests that lowering the concentrations of HPHC in e-cigarette aerosols may not result in proportionate harm reduction, and that lower HPHC exposure may be counterbalanced by increased use by people who think e-cigarettes are less harmful than traditional cigarettes. As a result, the evidence at hand does not fully support the claim that e-cigarettes are safe products or successful smoking cessation aids[21]. Following measures should be taken to prevent use of e cigarettes: It should be made illegal for young people to use E-cigarettes. E-cigarettes cannot be advertised as a risk-free substitute for cigarette smoking. E-cigarettes might be useful as quitting aids, but more reliable data are needed to show how effective they are[22]. Aldehydes produced by e-cigarette aerosols should be rigorously monitored because they are harmful even at extremely low amounts in order to reduce cardiovascular damage[23]. Acrolein levels in e-cigarette aerosols should be below 0.008 ppm, at which chronic exposure has not been associated with any adverse effects. Acetaldehyde and formaldehyde concentrations should be below 0.025 and 0.40 ppm, respectively. To protect consumers from unnecessary injury, device attributes could be controlled to adhere to these requirements[22,23]. It is the best to prevent new, uninitiated, and young people from experimenting with e-cigarettes.

To assist adolescents in restraining use and assisting them in quitting, targeted interventions are required. Adolescents' awareness of potential risks can be raised through evidence-based curriculum and communication campaigns, the provision of counseling and cessation tools, a review of current policies, and instruction of school administrators in product identification[23,24].

PUBLIC HEALTH POLICY RECOMMENDATIONS

To counter this trend, several public health policy actions are necessary. These include enforcing strict age restrictions to prevent underage sales, regulating marketing strategies to eliminate youth-targeted advertising, and applying taxation to reduce affordability. Mandatory health warnings on packaging that clearly outline cardiovascular risks should be implemented. Public awareness campaigns focusing on the dangers of ENDS, especially for cardiovascular health, are essential. Establishing robust monitoring systems to track adolescent usage patterns and funding local research into long-term health outcomes will further inform policy. Additionally, integrating ENDS regulations into existing tobacco control frameworks and requiring retail licensing can strengthen enforcement and oversight[25].

SOCIOECONOMIC ISSUES LEADING TO INCREASED TRENDS

Socio-economic factors such as education, urbanization, and media exposure significantly influence adolescent uptake of ENDS. Lower educational attainment among adolescents or their parents is associated with reduced awareness of the health risks of vaping, making adolescents more susceptible to experimentation[25]. Urbanization also plays a key role, as adolescents in urban areas encounter greater availability of vape shops and social environments that normalize ENDS use. Furthermore, media, especially social media platforms like Instagram and TikTok, amplify the appeal of vaping by portraying it as fashionable and harmless, further encouraging adolescents to initiate use. Together, these socio-economic dynamics create a high-risk environment for increased ENDS adoption among youth[9]. The summary of Biochemistry to measures of prevention is given below in Table 1.

Table 1 Biochemistry to measures of prevention.

Section	Key points
Biochemistry of E-cigarettes	E-cigarette aerosols contain propylene glycol, vegetable glycerin, nicotine, and flavoring agents like menthol, ethyl vanillin
	Variability in device design affects vapor production
	Some toxicants present, but extent of human exposure still unclear compared to traditional smoking
Rising trends of E-cigarettes in Pakistan	Pakistan's vaping market is growing rapidly, expected to generate $77.2 million by 2024
	Liberal regulations and flavored options increase youth appeal
	Socioeconomic and marketing factors drive the trend
Socioeconomic issues leading to increased trends	Lower education levels linked to poor awareness of vaping risks
	Urbanization increases access to vape shops
	Social media glamorizes vaping
	These factors create a high-risk environment for youth
Cardiovascular implications: Mechanisms, biomarkers, and long-term consequences	Nicotine induces endothelial dysfunction, raises heart rate and blood pressure
	Aerosols contain formaldehyde, acetaldehyde causing oxidative stress
	Ultrafine particles may cause endothelial injury
	Chronic use leads to arterial stiffness, inflammation (elevated CRP, IL-6, TNF-α)
	Adolescents more vulnerable due to developing systems
	Dual use (e-cigarettes + traditional cigarettes) amplifies risks
Measures of prevention	E-cigarette use among youth should be illegal
	E-cigarettes must not be advertised as safe alternatives
	Stricter control of harmful aldehyde levels
	Device regulations to limit toxic emissions
	Awareness campaigns, school interventions, and counseling are needed
	Evidence-based public health strategies required

CRP: C-reactive protein; IL-6: Interleukin-6; TNF-α: Tumor necrosis factor-alpha.

CONCLUSION

The emergence of e-cigarettes, also known as vaping, poses a multifaceted problem with significant consequences, especially among young people in Pakistan. E-cigarettes carry some risks even if they might be a less dangerous option than regular cigarettes. Strong regulations and oversight are essential given the carcinogens and other toxicants found in e-cigarette aerosols. Addressing the rising incidence of e-cigarette use among teenagers in Pakistan requires action to limit youth access, fight deceptive advertising, and support evidence-based cessation techniques.