The Vaping Debate No One’s Talking About
There is no doubt that there are significant dangers associated with e-cigarettes, especially for teens. But some public-health experts say for people who just can’t give up traditional smokes, vaping could help prevent unnecessary cancer deaths. Could there be a middle ground?
Chicagoan Jason Schneider and Atlanta native Lindsay Lightman* both smoke e-cigarettes. But the stories behind how they each got hooked are critically different, and the details and circumstances entrenched in those differences are emblematic of a stark divide that exists within the public-health community.
Schneider, a 31-year-old restaurant manager, was enjoying a few drinks with friends in the fall of 2018 when he ducked into a nearby corner store for some Marlboro Lights. A pack-a-day smoker for nearly a decade, he had never tried to quit; his doctor would occasionally ask if he wanted to try a tobacco-cessation medication, but Schneider found the thought of taking a drug unappealing.
That night at the bodega, he saw a display of Juul electronic cigarettes. Schneider knew from friends that e-cigs could be used discreetly, indoors even, and “with the Chicago winter coming, I thought, ‘I’ll try this. It would be nice to not have to go outside in the freezing cold to smoke.’” He bought a starter kit. “I only needed a couple of drags to feel the hit of nicotine instead of having to smoke an entire cigarette,” he says, adding that vaping—the term for smoking an e-cigarette—fit in easily with his usual smoking routine, which includes walking to the bus, before starting work, while checking email, making phone calls, and more. Three days after his inaugural vape, he was off traditional cigarettes for good.
Lightman’s love affair with e-cigs began with a much different spark. The 36-year-old graphic designer was just an occasional smoker: “An American Spirit here or there on weekends,” she says. Then, about one year ago, she tried vaping. Relatively odorless and with an uncannily resemblance to a USB stick, she loved how she could take quick, unnoticed puffs of her Juul while enjoying a latte in a café, in the bathroom after dinner when her kids were acting up, or while scrolling Instagram before bed. (It lives in her bra for easy access.) Perhaps the ultimate proof of her e-cig’s concealability? Lightman’s husband, whose mother, a lifelong smoker, died from lung cancer, has no clue about her “full on addiction,” nor do their middle school-aged son and daughter. “They would flip out,” she says. “They’re learning about e-cigarettes at school, and I’ve heard them say, ‘Why would people do that? It’s so stupid!’ And I’m just, like, ‘Yup.’”
Vaping: A Simmering Public-Health Debate
E-cigs have been sold in the U.S. since 2005. The battery-operated devices heat a liquid solution–most often containing nicotine, propylene-glycol flavoring agents and more–to create an inhalable aerosol. About 11 million U.S. adults currently smoke e-cigarettes.
But while e-cigs were ostensibly offered up as surrogates for adults attempting to quit, they quickly gained traction among adolescents and young adults, many of whom had never smoked anything. (A recent Los Angeles Times article describes them as “a new generation of nicotine addicts.”) Today, more than one in four high school students vapes, according to the 2019 National Youth Tobacco Survey. That, combined with a recent wave of vaping-related deaths and acute respiratory illnesses, has propelled the devices to the forefront of the public’s consciousness, with headlines like “E-Cig Vaping Led to Lung Cancer in Mice: What Does This Mean for Humans?” and “Michigan Teen Receives Double Lung Transplant After 'Enormous' Damage From Vaping.” And even at HealthCentral: “Why It’s Time to Stop Vaping Now.”
Newer to the mix, though, is a small but increasingly vocal group of public-health experts concerned that the potential benefits of e-cigarettes are being discounted and the harms, exaggerated. For them, adults like Schneider are proof that e-cigarettes can help people stop smoking traditional cigarettes, thereby reducing their exposure to known cancer-causing compounds created when tobacco is burned.
As David Abrams, Ph.D., a professor at the NYU College of Global Public Health, puts it, “By demonizing e-cigarettes, I think we have blown the biggest public-health opportunity we’ve had in 120 years, when the cigarette-rolling machine was invented.”
That may seem like an unpopular sentiment, but is it valid? We spoke to experts on both sides of the story to get the most up-to-date information. Keep reading to learn more about the dark side of vaping, along with the possible silver lining.
The Concerns About E-cigarettes
Every Thursday, the Centers for Disease Control and Prevention updates the number of cases of EVALI, the acronym now used by clinicians to describe a constellation of toxic lung effects being seen in some vapers (it stands for E-cigarette, or Vaping, Product Use-Associated Lung Injury). As of December 17, 2019, more than 2,500 cases of EVALI had been confirmed in the U.S. states, including 54 deaths.
Prior to the EVALI outbreak, e-cigs seemed to have developed a bit of a health halo, almost like a nontoxic version of a cigarette. “In high school, we would buy the disposable Blu e-cigarettes in mango flavor, thinking we were just ‘practicing’ smoking cigarettes with water vapor,” recalls Sara Weston*, now a 24-year-old SEO content editor living in Brooklyn. Only 13% of teens know that e-cigarettes contain nicotine; a whopping 66% think they’re inhaling just flavoring, according to the National Institute on Drug Abuse.
But e-cigs do contain nicotine, a tobacco derivative (see below), and vaping technology delivers the highly addictive substance into the bloodstream at faster rates than regular cigarettes. One Juul pod, for example, contains as much nicotine as a pack of 20 cigarettes, or about 200 puffs, and the company claims its e-liquid is formulated in such a way that it works up to 2.7 times faster than other e-cigarettes, potentially increasing the likelihood of addiction.
Because no combustion happens with e-cigarettes–meaning no tobacco is lit on fire–the number of carcinogens created and inhaled is dramatically reduced compared with traditional cigarettes…a fact noted by the American Cancer Society on its website.
But vape aerosol is cooler than tobacco smoke, allowing vapers to inhale more deeply. That means more nicotine; heavy metals like lead and nickel; flavoring agents; and other concerning compounds make their way deeper into the lungs, says Laren Tan, M.D., a pulmonologist and asthmatologist at Loma Linda University Health in California.
Diacetyl, a popular vape flavoring chemical, has been linked with irreversible lung disease. And certain e-cig flavors may be more damaging than others. A new Journal of the American College of Cardiology study, for instance, found cinnamon-flavored product to be more toxic to cells than other flavors. Some progress has been made in the past couple of months or so in terms of vape companies pulling flavored products from shelves, but thousands of e-liquid flavors are available, from mango to crème brulee to vanilla latte. Research suggests that flavors entice users to start vaping and hook them more quickly. (This is why flavors, with the exception of menthol, are banned from tobacco products.)
The Youth Factor
While Lightman thinks her preteens would be grossed out if they knew she vaped, chances are overwhelmingly high that they will one day take at least a few hits of their own: The practice has become commonplace among high schoolers, and use among middle school students continues to rise. The practice has exploded to the point where Pnina Weiss, M.D., medical director of the Pediatric Pulmonary Function Laboratory at the Yale-New Haven Children's Hospital, now routinely asks all of her adolescent patients, “Do you vape?”
Nicotine can harm adolescent brain development and may alter brain chemistry in ways that render their brains more susceptible to other addictive drugs, says the Truth Initiative, a national anti-tobacco public health organization. That same organization warns that young people who vape may be more likely to smoke conventional cigarettes in the future. Dr. Weiss adds that e-cig aerosol can also exacerbate pediatric asthma–even when inhaled secondhand.
Experts like Dr. Weiss and Robin Koval, president and CEO of Truth Initiative, are unsurprised by the surging number of underage vapers, pointing out that e-cig juice is widely available in kid-friendly flavors like gummy worm, cupcake, and Unicorn Vomit that, Dr. Weiss says, are “purely designed to lure in children and adolescents.” Koval adds that 97% of young vapers choose flavored e-juice, calling it “the number-one reason youth use e-cigarettes, along with ‘Everyone else is doing it.’”
Also troubling: About 16% of EVALI cases have been in minors, according to the CDC.
Are E-cigs a Public-Health Weapon in Disguise?
In light of all this, it might sound counterintuitive to hear that some medical experts remain in favor of vaping technology. But the reality, they say, is that with proper regulations (to keep them out of young hands) and exclusive use (i.e. no concurrent combustible cigarette consumption), e-cigarettes have the potential to revolutionize public health. (Everyone seems to agree that efforts to keep all tobacco- and nicotine-containing products, including e-cigarettes, away from those under age 18 need to be strengthened.)
Kenneth Warner, Ph.D., professor and dean emeritus of the University of Michigan School of Public Health, recognizes that the “mainstream of public health is vehemently opposed to vaping, and focused tunnel-vision-like on kids and vaping.” But he adds that it’s also “ignoring the adult smokers who are quitting by vaping.”
Abrams, the NYU professor, notes that 35 million people currently smoke cigarettes, killing nearly 500,000 Americans a year. “With vaping, the exposures to cancer-causing chemicals are probably closer to 95% to 98% less than with cigarette smoke,” he says. “That’s massive. If just 10% of current smokers switched completely to e-cigarettes for the next 10 years, we'd save six to seven million lives that would otherwise be lost due to cigarette smoking, plus we’d spare millions more chronic diseases made worse by cigarettes.” It’s worth noting that Abrams is a past executive director of the Schroeder Institute for Tobacco Research and Policy Studies at the Truth Initiative, and he helped found the institute in 2008. (In his interview with HealthCentral.com, Abrams confirmed he does not accept compensation from any e-cigarette company.)
The problem, he says, is that many anti-tobacco experts assume an all-or-nothing stance when it comes to smoking cessation, when a lesser-of-two-evils approach might be more prudent. “I think a lot of anti-e-cigarette people talk about the small level of absolute harm—the harm involved with vaping compared with not using any tobacco at all–and forget to tell you about the relative harm compared to combustible cigarette smoke.” Abrams cites a 2018 Journal of the American Medical Association study (supported with federal funds from the National Institute on Drug Abuse and National Institutes of Health, among other entities), which found “much lower” exposure to tobacco-related constituents, nicotine and other compounds in exclusive e-cigarette users compared with exclusive cigarette smokers. (Between 10% and 98% less, depending on the compound.)
Abrams says he wishes public-health officials could be as comfortable with a harm-reduction approach to nicotine as they are with harm reduction and teen-sex education or underage-alcohol consumption. “We don’t expect teens to not have sex, so we tell them, ‘If you’re going to have sex, please use a condom.’ We say to teens, ‘Don’t drink, but if you have been drinking, don’t get in a car with someone who’s been drinking.’ Why have we found a way to do that, but we can’t do it for nicotine?”
“Vaping obviously is not harmless,” he continues, “but we don’t want to discourage e-cig users to go back to smoking cigarettes. If you’re using, choose to use the least harmful of the products.”
David Sweanor, a Canadian law professor who’s worked in global anti-tobacco public health efforts for more than 30 years, called this approach “realistic harm reduction, not unrealistic harm elimination” in a 2016 Huffington Post piece, where he favorably compared vaping to aspartame. “While going cold turkey is an unlikely outcome for many,” he wrote, “products that mitigate harms can have positive effects even when people do not give up the activity entirely–getting nicotine without smoke or satisfying a sweet tooth without sugar, for example.”
As for the recent spate of EVALI cases, the CDC has now linked the majority of them—80%—to vaping tetrahydrocannabinol (THC), the psychoactive compound in cannabis. (A counterfeit THC brand called Dank Vapes has been largely implicated.) In a November 8, 2019, telebriefing, the CDC announced that vitamin E acetate, a sticky oil often used in THC vaping cartridges, may be a possible culprit behind EVALI.
“It’s not happening from commercial e-cigarettes with nicotine in them,” Abrams says. “It’s these adulterated vape products.”
On October 4, 2019, the FDA released a consumer alert, urging the public to avoid vaping products that contain THC; to avoid using any vaping products, THC-containing or not, obtained off the street or from an illicit source; and to not modify or add any substance, such as TCH or other oils, to vaping products, including those purchased through retail establishments.
In terms of underage vaping, Abrams and his like-minded colleagues are staunchly against it. “No teen should use a nicotine product, and we should do everything we can to keep e-cigarettes away from anyone under 21, just like we do with alcohol.” He concedes that some non-smoking teens who try e-cigs will transition to smoking combustible cigarettes, “but it’s not a gateway to lifetime of smoking. Probably those same teens will try marijuana and drinking. Most of them are just trying things out.” Backing him up: A 2018 Nicotine & Tobacco Research study coauthored by Abrams and several Truth Initiative staff, including the current Chief Research Officer, found that when you follow teens for 2.5 years, those who vaped at the outset are likely to be neither vaping nor smoking 2.5 years later.
But others disagree. The National Academies of Science, Engineering and Medicine states there is "substantial evidence" that if a young person uses an e-cigarette, he or she is at increased risk of using traditional cigarettes. And Koval says it’s not just one-time use, citing research showing that young adults who have never smoked tobacco at all, in any form, are four times more likely to go on and use regular cigarettes” within 18 months of trying e-cigarettes.
Where We Stand Now
The e-cigarette landscape is evolving on a daily basis. Research continues to emerge favoring both sides, and the way that data is interpreted varies wildly, depending on who you ask. For example, consider the following three examples, all published in 2019:
A University of Michigan analysis determined that “the upside health benefit associated with e-cigarettes, in terms of their potential to increase adult smoking cessation, exceeds their downside risk to health as a result of their possibly increasing the number of youthful smoking initiators.”
The Archives of Disease in Childhood published a case report titled “Life-threatening Hypersensitivity Pneumonitis Secondary to E-cigarettes,” about a young nicotine e-cigarette user who went into respiratory failure. The authors warned that health officials must “consider e-cigarettes as ‘much safer than tobacco’ at our peril.”
A British Medical Journal study, in which scientists from four leading U.S. universities reviewed thousands of peer-reviewed vaping-related scientific papers, concluded that “current knowledge…is insufficient to determine whether the respiratory health effects of e-cigarette are less than those of combustible tobacco products.”
Confounding matters, with influenza season upon us, CDC officials worry that EVALI cases may be confused with flu, and vice versa, thanks to shared respiratory or gastrointestinal symptoms.
And new products continue to hit the market. In early October 2019, Altria (the parent company for Philip Morris USA) began selling IQOS (also called “HeatSticks”), electronic gadgets that heat a plug of tobacco without burning it, purportedly creating fewer toxins than cigarette smoke.
President Trump recently proposed a ban on all flavored e-cigarettes, including mint and menthol, although it was softened in a way that would now allow those cooling flavors–which are among the most popular–to remain on the market. On October 17, 2019, Juul voluntarily stopped selling non-tobacco, non-menthol-based flavors, including creme, fruit, and cucumber.
No vaping product has yet been approved by the FDA for tobacco cessation purposes. E-cigarette companies have until May of 2020 to submit applications to the FDA that make the case that allowing their products on the market would be “appropriate for the protection of public health,” explains Stanton Glantz, Ph.D., director of the UCSF Center for Tobacco Control Research and Education – a claim Dr. Glantz has outspokenly criticized. “The more we learn about e-cigarettes,” he says, “the more dangerous they look. The heart and lung disease risks appear similar to cigarettes and cancer evidence is emerging. People should follow the CDC’s advice and stop using all e-cigarettes, whether nicotine or THC.” (In mid-November, the American Medical Association called for an immediate ban on all e-cigarette and vaping products from the U.S. market that are not FDA-approved.)
Some, like Dr. Weiss, maintain that there is “no data whatsoever” suggesting vaping is an effective tobacco cessation strategy, and want to see all e-cigarettes removed from the market—or, at the very least, the flavored products. (A 2019 British Medical Journal study says most vapers still smoke combustible cigarettes.) The FDA and the American Lung Association say no e-cigarette has been found to be safe and effective in helping smokers quit. Yet Drs. Abrams and Warner says they can work, possibly even doubling the successful quit rate among smokers compared with nicotine replacement therapy. (According to a 2019 New England Journal of Medicine study, though that study also included smoking cessation counselling.)
The safest course, Abrams says, is to stop smoking and, “if you haven’t started smoking, don’t start. Whether you're a teen or adult smoker, you should never use a combustible tobacco product.”
As someone who has used both, Lightman is starting to pay closer attention. She recently tried quitting e-cigarettes. “I went cold turkey because I was concerned I was using it too much,” she says. The withdrawal symptoms, “felt like PMS times five—I was headachy, overemotional. I had the chills. Then I saw my friend with her Juul, so I took a puff. Now I’m back to carrying it in my bra.”
*Name and identifying details have been changed.
History of E-cigs: Consumer Advocates for Smoke Free Alternatives Association. (n.d.). “A Historical Timeline of Electronic Cigarettes.” casaa.org/historical-timeline-of-electronic-cigarettes/http://www.casaa.org/historical-timeline-of-electronic-cigarettes/
How E-cigs Work: Loma Linda University Health. (2018). “E-cigarettes could lead to serious, long-term lung damage, lung specialist says.” news.llu.edu/patient-care/e-cigarettes-could-lead-serious-long-term-lung-damage-lung-specialist-says
Flavoring of E-cigs: BMJ. (2019). “What are the respiratory effects of e-cigarettes?” bmj.com/content/366/bmj.l5275.full
How Many Adults Smoke E-cigs: Annals of Internal Medicine. (2018). “Prevalence and Distribution of E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016.” annals.org/aim/article-abstract/2698112/prevalence-distribution-e-cigarette-use-among-u-s-adults-behavioral
What Teens Know About E-cigs: National Institute of Health. (2016). “Teens and E-cigarettes.” drugabuse.gov/related-topics/trends-statistics/infographics/teens-e-cigarettes
Nicotine Content in Juul (1): Tobacco Control. (2019). “Recognition, use and perceptions of JUUL among youth and young adults.” tobaccocontrol.bmj.com/content/28/1/115
Nicotine Content in Juul (2): Truth Initiative. (2018). “6 important facts about JUUL.” truthinitiative.org/research-resources/emerging-tobacco-products/6-important-facts-about-juul
Nicotine Content in Juul (3): Truth Initiative. (2019). “E-cigarettes: Facts, stats and regulations.” truthinitiative.org/research-resources/emerging-tobacco-products/e-cigarettes-facts-stats-and-regulations
Diacetyl & Lung Disease Link: The National Institute for Occupational Safety and Health (NIOSH). (2017). “FLAVORINGS-RELATED LUNG DISEASE.” cdc.gov/niosh/topics/flavorings/default.html
Cinnamon-flavoring and Lung Disease Incidence: Journal of the American College of Cardiology. (2019). “Modeling Cardiovascular Risks of E-Cigarettes With Human-Induced Pluripotent Stem Cell–Derived Endothelial Cells.” sciencedirect.com/science/article/pii/S0735109719346960?via%3Dihub
Flavor Ban on Tobacco Products: Food and Drug Administration. (2018). “Menthol and Other Flavors in Tobacco Products.” fda.gov/tobacco-products/products-ingredients-components/menthol-and-other-flavors-tobacco-product
Vaping Use Among Middle and High School Students: Centers for Disease Control. (2018). “Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018.” cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s_cid=mm6745a5_w
Long Term Effects of Vaping: Truth Initiative. (2019). “What are the long-term effects of vaping?” truthinitiative.org/research-resources/emerging-tobacco-products/what-are-long-term-effects-vaping
Tobacco Use in the U.S.: Centers for Disease Control. (2019). “Burden of Tobacco Use in the U.S.” cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html
Exposure to Tobacco Constituents in Smokers vs. E-cig Users: JAMA Open Network. (2018). “Comparison of Nicotine and Toxicant Exposure in Users of Electronic Cigarettes and Combustible Cigarettes.” jamanetwork.com/journals/jamanetworkopen/fullarticle/2718096
Lung Disease and THC Vaping: Centers for Disease Control. (2019). “Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products.” cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
Dank Vape Implication: Centers for Disease Control. (2019). “E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury — Illinois and Wisconsin, April–September 2019.” cdc.gov/mmwr/volumes/68/wr/mm6839e2.htm?s_cid=mm6839e2_w
Nov. 8th CDC Briefing: Centers for Disease Control. (2019). “Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-cigarette Use, or Vaping.” cdc.gov/media/releases/2019/t1108-telebriefing-vaping.html
NASEM Statement on E-cigs: American Lung Association. (2019). “E-cigarettes and Lung Health.” lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html
British Medical Journal Study: BMJ. (2019). “What are the respiratory effects of e-cigarettes?” bmj.com/content/366/bmj.l5275.full
New Vaping Products: Journal of the American Heart Association. (2019). “Acute Effects of Heat‐Not‐Burn, Electronic Vaping, and Traditional Tobacco Combustion Cigarettes: The Sapienza University of Rome‐Vascular Assessment of Proatherosclerotic Effects of Smoking (SUR‐VAPES) 2 Randomized Trial.” ahajournals.org/doi/10.1161/JAHA.118.010455
President Trump Ban on Flavored E-cigs: AAFP. (2019). “AAFP Hails White House Bid to Ban Flavored E-Cigarettes.” aafp.org/news/health-of-the-public/20190927whecigban.html
Juul Flavor Ban: Juul. (2019). “JUUL LABS SUSPENDS SALE OF NON-TOBACCO, NON-MENTHOL-BASED FLAVORS IN THE U.S.” newsroom.juul.com/juul-labs-suspends-sale-of-non-tobacco-non-menthol-based-flavors-in-the-u-s/
Vapers Still Smoke Cigarettes: Tobacco Control. (2019). “JUUL use and reasons for initiation among adult tobacco users.” tobaccocontrol.bmj.com/content/28/6/681?int_source=trendmd&int_medium=cpc&int_campaign=usage-042019
Quitting Smoking with Vaping Study: The New England Journal of Medicine. (2019). “A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy.” nejm.org/doi/full/10.1056/NEJMoa1808779