Electronic devices to smoke (DEF, acronym in Portuguese) are equipment that aim to simulate the act of tobacco smoking. DEF can be classified according to their matrix: solid, liquid, or hybrid (Figure 1). As an example, we can mention electronic cigarettes (e-cigarettes), which consist of a liquid matrix, and heated tobacco products that use a solid matrix.

Some brands of DEF have achieved great popularity among young people, especially because of their attractive yet discreet design, technological appeal, high concentrations of nicotine salts, attractive flavors, and aggressive marketing ¹1. Silva ALO, Moreira JC. Why electronic cigarettes are a public health threat? Cad Saúde Pública 2019; 35:e00246818..

These products are banned in Brazil through the Brazilian Health Regulatory Agency’s (Anvisa) Board Resolution n. 46/2009²2. Ministério da Saúde. Resolução de Diretoria Colegiada nº 46, de 28 de agosto de 2009. Proíbe a comercialização, a importação e a propaganda de quaisquer dispositivos eletrônicos para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União 2009; 31 aug., which could explain the low prevalence of use when compared to countries that have authorized their commercialization ³3. Latuf G. Relatório final de análise de impacto regulatório sobre dispositivos eletrônicos para fumar. https://www.gov.br/anvisa/pt-br/assuntos/regulamentacao/air/analises-de-impacto-regulatorio/2022/25351-911221-2019-74-relatorio-final-de-analise-de-impacto-regulatorio-sobre-dispositivos-eletronicos-para-fumar (accessed on 13/Sep/2023).
https://www.gov.br/anvisa/pt-br/assuntos... . According to the Brazilian National Health Survey (PNS 2019, individuals ≥ 15 years old) ⁴4. Instituto Brasileiro de Geografia e Estatística. PNS - Pesquisa Nacional de Saúde. https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?=&t=resultados (accessed on 02/Sep/2021).
https://www.ibge.gov.br/estatisticas/soc... the prevalence of use of DEF is 0.64%. In addition, a study ⁵5. Bertoni N, Szklo AS. Dispositivos eletrônicos para fumar nas capitais brasileiras: prevalência, perfil de uso e implicações para a Política Nacional de Controle do Tabaco. Cad Saúde Pública 2021; 37:e00261920. indicates that dual use is 10 times higher in the 18-24 age group when compared to the 35+ age group; half of those who have used DEF in their lifetime have never smoked, 80% of them are aged 18-34; and a large portion had a high level of education. For these reasons, some authors consider DEF to be a threat to tobacco control in Brazil ⁵5. Bertoni N, Szklo AS. Dispositivos eletrônicos para fumar nas capitais brasileiras: prevalência, perfil de uso e implicações para a Política Nacional de Controle do Tabaco. Cad Saúde Pública 2021; 37:e00261920.. In this scenario, at the end of January 2023, an advertisement for an e-cigarette branded IZ Health, composed of vitamins and other nutrients, circulated on social networks. The company advertisement claimed that these vitamins would be absorbed by the mucous membranes. This advertisement raised a number of discussions and criticisms, especially from health professionals ⁶6. Pagno M. Proibido pela Anvisa, "vape com vitaminas" para exercícios é criticado por ineficácia e risco de lesão. G1 2023; 31 jan. https://g1.globo.com/saude/noticia/2023/01/31/proibido-pela-anvisa-vape-com-vitaminas-para-exercicios-e-criticado-por-ineficacia-e-risco-de-lesao.ghtml.
https://g1.globo.com/saude/noticia/2023/... . In the video, a young athlete in a gym reports using e-cigarettes to boost one’s vigor and energy to perform exercises and daily tasks.

About the product

According to photos and internet searches, the product called “Power”, would consist of vitamin B₁₂, l-carvone, l-theanine, and caffeine. The packaging provided no information about the manufacturer or importer. The person responsible for advertising the product stated that it did not contain nicotine nor tobacco.

The research indicated that the person responsible for the product apparently put their logo and colors on a product manufactured by the U.S. company Health Vape. These products were only found on online stores aimed at the Brazilian public, so we can assume that those responsible for the product were Brazilian, despite the fact that the images in the advertisements were in English.

The investigation also revealed that in addition to the model indicated to increase physical vigor, there were also formulations indicated for rejuvenation, relaxation, immune support, sleep improvement, and maintenance of focus. Box 1 shows models, declared compositions, and manufacturer’s indications. The declared compositions included vitamins, amino acids, collagen, and plant extracts.

When analyzing the advertised composition of the manufacturers’ products, it is noticeable that the concentrations of the substances used are absent. On the advertised packaging, it is also not possible to identify the composition of the vehicle used in the product. In the case of Health Vape, the possible origin of the Brazilian version, the manufacturer stated that the vehicle was propylene glycol.

Intake of nutrients via respiratory tract

When analyzing the declared components of the product (Box 1), it can be seen that some components present inconsistent data on their efficacy even when orally consumed. Excepting vitamin B₁₂, the components hold no tests of absorption or equivalence via airways. Thus, these products hold no indication of benefiting their users ⁷7. Marra MV, Bailey RL. Position of the Academy of Nutrition and Dietetics: micronutrient supplementation. J Acad Nutr Diet 2018; 118:2162-73.. The promotion of DEF with nutrients is similar to that found on the U.S. market ⁸8. Basáñez T, Majmundar A, Cruz TB, Allem JP, Unger JB. E-cigarettes are being marketed as "vitamin delivery" devices. Am J Public Health 2019; 109:194-6..

About the safety of consuming these products

The advertiser of the product indicates that these products are safe and beneficial to health. However, when we looked at the components (Box 1), we found that none of the substances used have been tested for inhalation toxicity. In some cases, when the advertiser states that the consumption of these products is safe, ignores, for example, that excessive consumption of vitamin A can cause damage to health, especially considering that the concentrations are not shown.

Moreover, it is important to remember that a substance that is safe for oral consumption will not necessarily be safe for inhalation. Diacetyl (2,3-butanediene) is a good example, which is used as a flavoring in several products, including microwave popcorn and butter flavoring. However, the literature presents cases of occupational exposure to diacetyl, where people inhaled the compound and developed bronchitis obliterans, also known as “popcorn lung” ⁹9. White AV, Wambui DW, Pokhrel LR. Risk assessment of inhaled diacetyl from electronic cigarette use among teens and adults. Sci Total Environ 2021; 772:145486.. Diacetyl has also been found in some brands of e-cigarettes and could be potentially harmful to individuals who smoke them ⁹9. White AV, Wambui DW, Pokhrel LR. Risk assessment of inhaled diacetyl from electronic cigarette use among teens and adults. Sci Total Environ 2021; 772:145486..

Another relevant case is vitamin E acetate, usually consumed as a food supplement and recommended for the treatment of vitamin E deficiency. However, this same substance is one of the main suspects of having caused the cases of EVALI (chemical pneumonia caused by the use of e-cigarettes), which caused 2,870 hospitalizations and 68 deaths (2020 data) in the United States ¹⁰10. Centers for Disease Control and Prevention. Outbreak of lung injury associated with the use of e-cigarettes, or vaping, products. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html (accessed on 08/Feb/2023).
https://www.cdc.gov/tobacco/basic_inform... .

Thus, the claims that a substance is safe when consumed orally cannot be used to assert that this same substance would be safe when inhaled.

Vitamins and nutrients in smoking products

The scientific literature describes that the use of vitamins and nutrients in DEF, whether they contain nicotine or not, has been practiced since at least 2018, and in addition to the indications mentioned above, brands sold on the international market are also indicated for weight control by appetite suppression ⁸8. Basáñez T, Majmundar A, Cruz TB, Allem JP, Unger JB. E-cigarettes are being marketed as "vitamin delivery" devices. Am J Public Health 2019; 109:194-6..

However, the use of vitamins in other tobacco products dates back to the 1980s-1990s, and basically began to be studied by the tobacco industry in an attempt to mitigate the health damage caused by cigarettes ¹¹11. Rabinoff M, Caskey N, Rissling A, Park C. Pharmacological and chemical effects of cigarette additives. Am J Public Health 2007; 97:1981-91.^,1212. Glantz SA, Slade J, Bero LA, Hanauer P, Barnes DE. The cigarette papers. Berkeley: University of California Press; 1996.. Several substances have been tested, including β-carotene, vitamins B₁, B₂, C and E, provitamin A, catechin, eugenol, bioflavonoids, vanillyl, tryptophan, turmeric, glutathione, ethyl salicylate, and essential oils. Even the use of genetically modified tobacco plants with genes to produce beta carotene has been considered ¹¹11. Rabinoff M, Caskey N, Rissling A, Park C. Pharmacological and chemical effects of cigarette additives. Am J Public Health 2007; 97:1981-91..

A “vitaminized” cigarette was commercialized in the Canadian market in 2006. The VitaCig, a conventional cigarette with added vitamin C would be less likely to cause stains on the teeth, hold less odor, and be healthier by guaranteeing doses of vitamin for smokers, at least according to the manufacturer ¹³13. Lowe A. Healthy cigarettes? Trend Hunter 2006. https://www.trendhunter.com/trends/vitacig (accessed on 05/Feb/2023).
https://www.trendhunter.com/trends/vitac... .

Research aimed at evaluating the use of vitamins to mitigate the damage caused by cigarettes may originate from antioxidant effects of vitamins, which might be a possible defense against the free radicals present in tobacco smoke and from the fact that smokers have reduced levels of some vitamins ¹⁴14. Chow CK, Thacker RR, Changchit C, Bridges RB, Rehm SR, Humble J, et al. Lower levels of vitamin C and carotenes in plasma of cigarette smokers. J Am Coll Nutr 1986; 5:305-12.. However, this idea seemed to be weakened by a study suggesting that β-carotene supplementation in smokers could increase the incidence of lung cancer and heart disease ¹⁵15. Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med 1994; 330:1029-35..

In the advertisement, the product is used in an enclosed environment, implying that it would not impact the people’s health. This type of attitude, in addition to being a health infraction, as discussed below, induces the population to believe that these products would not cause air quality problems for non-users. However, even in products without tobacco or nicotine, their smoke emissions are potentially harmful to health and the use of these products in enclosed public spaces should not be encouraged ¹⁶16. Bhatt JM, Ramphul M, Bush A. An update on controversies in e-cigarettes. Paediatr Respir Rev 2020; 36:75-86..

Legislation

Considering these products only in a recreational context and as a simulacrum of a cigarette, DEF cannot be marketed in Brazil, as provided by the Anvisa in Board Resolution n. 46/2009²2. Ministério da Saúde. Resolução de Diretoria Colegiada nº 46, de 28 de agosto de 2009. Proíbe a comercialização, a importação e a propaganda de quaisquer dispositivos eletrônicos para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União 2009; 31 aug.. Advertising them is also prohibited.

However, this situation exemplifies the challenges of regulating advertisements on the world wide web, especially on social networks. Due to its nature and ability to target specific groups, social networks poses great challenges for tobacco control policies and points to the need to develop specific strategies and tools ¹⁷17. Kong G, Laestadius L, Vassey J, Majmundar A, Stroup AM, Meissner HI, et al. Tobacco promotion restriction policies on social media. Tob Control 2022; (Online ahead of print)..

Another important point is that in the advertisement, e-cigarettes is used in a gym, an action forbidden by Law n. 9,294/1996¹⁸18. Brasil. Lei nº 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4° do art. 220 da Constituição Federal. Diário Oficial da União 1996; 16 jul., which prohibits the use of any smoking product derived or not from tobacco in enclosed collective environments.

We should also remember that the manufacturer alleges unproven therapeutic properties, which could possibly fit the Brazilian Penal Code¹⁹19. Brasil. Decreto-Lei nº 2.848, de 7 de dezembro de 1940. Código Penal. Diário Oficial da União 1940; 31 dec., specifically Chapter III (Crimes Against Public Health) articles 283 and 284, which deal with quackery (inculcating or announcing a cure by secret or infallible means) and faith healing (prescribing, administering, or habitually applying any substance) .

In addition to having committed a sanitary infraction by failing to comply with Anvisa’s resolution, this product could also be subject to criminal prosecution. It could also be debated whether advertising on social networks, which is available for children to watch without any warning, could fit other legislation, such as the Statute of the Child and Adolescent.

It is important to mention that Anvisa’s Board Resolution n. 46/2009²2. Ministério da Saúde. Resolução de Diretoria Colegiada nº 46, de 28 de agosto de 2009. Proíbe a comercialização, a importação e a propaganda de quaisquer dispositivos eletrônicos para fumar, conhecidos como cigarro eletrônico. Diário Oficial da União 2009; 31 aug. is currently being revised, and tobacco companies have been requesting that these products be legally marketed, as these products would be a safer alternative for adult smokers of conventional cigarettes.

However, as aforementioned, the data suggest that these products are particularly appealing for younger people, those who have never smoked conventional cigarettes, and those with higher levels of education, thus posing a threat to tobacco control policies in Brazil ⁵5. Bertoni N, Szklo AS. Dispositivos eletrônicos para fumar nas capitais brasileiras: prevalência, perfil de uso e implicações para a Política Nacional de Controle do Tabaco. Cad Saúde Pública 2021; 37:e00261920.. The fact that these products are prohibited in Brazil could explain the relatively low prevalence of use among younger people, compared to other countries ³3. Latuf G. Relatório final de análise de impacto regulatório sobre dispositivos eletrônicos para fumar. https://www.gov.br/anvisa/pt-br/assuntos/regulamentacao/air/analises-de-impacto-regulatorio/2022/25351-911221-2019-74-relatorio-final-de-analise-de-impacto-regulatorio-sobre-dispositivos-eletronicos-para-fumar (accessed on 13/Sep/2023).
https://www.gov.br/anvisa/pt-br/assuntos... . Further research would be important to assess the impacts of this type of advertising on the regulatory review process or on the consumption patterns of these products.

Final considerations

E-cigarettes with added vitamins and other nutrients, in addition to lacking any proof of health benefits, can cause damage to health. Advertisements and claims of this type try to exploit the popular belief, not always supported by scientific evidence, that nutritional supplementation in healthy individuals would bring health benefits.

This type of products are an additional challenge for health professionals, because as well as holding technological appeal and a beautiful design, they also carry claims, not scientifically proven, of health benefits, using social networks that allow these products to be advertised and marketed without any regulation.

Therefore, information campaigns to the population, stricter enforcement actions against these manufacturers, and discussing the responsibilities of social networks would be necessary initiatives to ensure that the national tobacco control policy is preserved.

Acknowledgements

I would like to thank the University of California San Francisco (UCSF, United States) and the Brazilian Health Regulatory Agency (Anvisa). The statements and opinions expressed in the article are those of the author and are based on current scientific evidence and do not represent any institutional guidance and/or opinion of UCSF, Anvisa, the Brazilian Ministry of Health, and/or the Brazilian Government.

References

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