You have probably seen a futuristic-looking hunk of metal clutched in the hands of a passing stranger, followed by seemingly endless, thick clouds of sweet-smelling smoke.

E-cigarette. E cig. Mod. Tank system. Vape pen. E-hookah. All of them are names for cigarettes’ flavored and more modern new competitor that has become incredibly popular with adolescents.

But are all e-cigarettes created equal?

As it turns out, there are two different types of e-cigarette systems, each carrying a different set of risks.  And for parents who are worried about their kids using e-cigarettes, it’s important to know the difference between the two, say a Mass General research team led by Jonathan Winickoff, MD, MPH, director of Pediatric Research at the Tobacco Research and Treatment Center.

E-Cigarette Break Down

An e-cigarette is a battery-operated device that contains a solution, called e-liquid, which is vaporized for the user to inhale using a heated atomizer. The solutions typically contain nicotine, though not always, as well as flavorings, and other potentially harmful chemicals and ultrafine particles.

The two types of e-cigarettes are known as open systems and closed systems. Open system e-cigarettes—those futuristic hunks of metal that we referenced at the beginning—involve rechargeable batteries with reservoirs that can be refilled manually with e-liquid.

Closed system e-cigarettes either have pre-filled, disposable cartridges that attach to rechargeable battery (reusable closed system), or are single-use products that cannot be recharged (disposable closed system).

Most US tobacco companies do not make refillable liquid for their e-cigarettes. Instead, they opt for closed system products with replaceable cartridges, which are non-modifiable. Researchers note that tobacco companies have dealt with regulatory issues in the past, but their history with combustible cigarettes has forced them to produce reliable, consistent consumer products with accurate ingredient and nicotine labels.

Researchers are finding the same may not be true about many independent, open system manufacturers, however.

Open system e-cigarettes are largely sold at vape stores and can be refilled with any e-liquid. After doing some digging, Mass General researchers found that the manufacturers of open system e-cigarettes have faced safety issues due to a lack of regulatory oversight. These products were often found to display inaccurate nicotine concentration levels, contain diacetyl (a chemical used to create a butter-like flavoring that is being investigated for links to lung disease) when labeled “diacetyl-free,” and have lithium batteries that can occasionally explode.

What Research Shows

What was concerning to researchers was that, according to a survey involving approximately 25,000 adolescents, most of those who had used e-cigarettes within the last 30 days reported starting out using closed systems and transitioning to open systems. This suggests that the closed system e-cigarette, while generally safer, serves as a starter product that paves the way for the use of a more risky, unregulated open-system e-cigarette.

The survey also indicated most adolescents who were regular e-cigarette users preferred rechargeable, refillable, open system e-cigarettes with flavored e-liquid, which were most often purchased at vape shops.

Research has shown that open system e-cigarettes are associated with more frequent and established use, and they are also believed to deliver more nicotine into the bloodstream than their closed system counterparts.

Moving Forward

Seeing as how the vaping trend does not seem to be slowing down any time soon, researchers at Mass General provided a few suggestions in their study for regulations and best practices in the future.

• E-cigarettes are currently available for sale to anyone aged 18 and older, and considering most adolescents got their e-cigarettes from friends, it may be worth including them in Tobacco 21 sales regulation. High school students would be less likely to be connected to 21-year-olds, which could reduce their access to tobacco from older buyers. 
• Since most adolescents purchased their e-cigarettes from vape shops, it may be helpful to promote stronger enforcement of existing regulations at these locations. 
• Targeted counseling for adolescents could help to increase knowledge and awareness surrounding the risks of different e-cigarette systems.

In short: e-cigarettes may not be as harmful combustible cigarettes, but they are not completely without risk.

According to  a recent radio interview with Dr. Winickoff, adolescents using e-cigarettes “are getting higher levels of nicotine than they were getting with being regular teen tobacco users…they can conceal these devices, they can use them more frequently, and they can inhale more rapidly.”

This means they are more easily putting harmful additives that may not always be included on the label into their bodies; not to mention their flavors make them more attractive.

While not much is known about the long-term risks, and though closed systems appear to be less risky than open systems, the best advice may be to educate adolescents on the risks of both systems and encourage them not to pick up the habit in the first place.

About the Mass General Research Institute
Research at Massachusetts General Hospital is interwoven through more than 30 different departments, centers and institutes. Our research includes fundamental, lab-based science; clinical trials to test new drugs, devices and diagnostic tools; and community and population-based research to improve health outcomes across populations and eliminate disparities in care.
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