Over the decades, given public health concerns, the tobacco industry has tried to find ways to make cigarette smoking less dangerous. Some of the changes—such as added filters and marketing of “light” cigarettes—were an illusion of reduced harm. They were market successes that did not actually reduce harm to consumers. Today, electronic cigarettes (e-cigarettes) and vaping have garnered a reputation as a safer way to consume nicotine and possibly a way to quit combustible cigarettes. Nicotine is the active ingredient in tobacco that is responsible for its pleasurable effects and is one of the most addictive substances known.
In this editorial, I discuss the relative harms of vaping compared to smoking and the evidence regarding the effectiveness of e-cigarettes for quitting smoking.
1. Vaping E-cigarettes is Less Harmful than Smoking Cigarettes.
Few things are as dangerous as smoking a traditional combustible cigarette. Cigarettes cause death in two out of three long-term users. If the comparison is to cigarettes, then e-cigarettes are likely less hazardous on a per unit basis, but that doesn’t mean vaping is completely safe or healthy.
When people inhale smoke from a cigarette, they’re taking nicotine and other chemicals into their lungs, where those chemicals enter the bloodstream and then travel quickly to the brain. Vaping follows the same route, except instead of burning tobacco leaves to release the nicotine, plastic e-cigarettes use batteries to heat nicotine-containing liquid to an aerosol. The inhaled aerosol carries the nicotine and some other chemicals to the lungs, into the bloodstream, and then quickly to the brain. The rapid delivery of high levels of nicotine to the brain is what creates the addiction. Depending on the device, people can become as addicted to vaping as to smoking.
Vaping and smoking both can deliver many substances in addition to nicotine, including ultrafine particles, heavy metals, volatile organic compounds, and other cancer-causing chemicals. However, levels of these toxicants typically are far lower with vaping than with smoking. For this reason, if a person is a chronic, heavy smoker, switching completely to vaping should result in less harm. Dual using (smoking plus vaping), however, provides no health benefit and is fairly common. And uptake of vaping by young people who would not otherwise smoke cigarettes is a serious public health concern because more adolescents in the United States are having their brains exposed to nicotine than in previous years.
2. The Flavors in E-cigarettes Hook Kids and Can Damage Cells in the Lungs.
More than 8 in 10 teens in the US who report vaping, report using a non-tobacco flavored e-cigarette. Chemicals are used to create the flavors (e.g., mango, mint, candy-flavors) that contribute to making e-cigarettes so popular among young people. The CDC reports that among teens vaping nicotine in the past month, 83% used a non-tobacco flavored product. Several of the chemicals used to create certain flavors such as pulegone (mint) and diacetyl (creamy flavors) have been shown to damage cells in the lungs. Although these chemicals have FDA approval to be in other consumer products, they can have harmful effects when heated and repeatedly inhaled into the lungs. Vaping can cause permanent damage to the small airways of the lungs and impair the immune functions of the lungs.
3. The Long-Term Effects of Vaping are Unknown.
Although documented effects of nicotine vaping include chronic cough, bronchitis, asthma exacerbation, and pneumonia, e-cigarettes haven’t been around long enough for researchers to determine the long-term risks associated with their use. There’s also a lot of variability in the products, which complicates studies. The variability and lack of knowledge on product safety is due to the way e-cigarettes entered the US market and have been largely unregulated to date. A court determined e-cigarettes are tobacco products and ruled they could stay on the open market as long as the companies didn’t make therapeutic claims. That is, the e-cigarette companies couldn’t claim they helped people quit smoking. The companies were creative and instead marketed their products as “switching” devices or used product names like “Fin,” a Latin root meaning ‘end.’ With lack of regulation, thousands of different product lines were developed and sold, varying greatly in their battery power, flavors, nicotine levels, and other components. The court’s ruling also affected research. In the US, researchers cannot study e-cigarettes in randomized controlled trials to see if they actually help people quit smoking.
The best smoking cessation trial to date comes from the UK. Adults who were smoking received cessation counseling and were randomized to receive either e-cigarettes or nicotine replacement medications (such as the nicotine patch or gum). Those randomized to e-cigarettes were significantly more likely to quit smoking (18%) compared to those who received nicotine replacement medications (10%). However, among those who quit smoking using e-cigarettes, 80% were still using e-cigarettes a year later, whereas only 9% of those who quit smoking using nicotine replacement products were still using nicotine replacement. A concern is that e-cigarettes may continue the addiction to nicotine, albeit to a product that should be less harmful than smoking, if the switch is complete (not using both).
E-cigarette devices also can be used to vape other substances, including cannabis and other drugs, and even less is known about those health effects. Some cannabis vaping liquids contain vitamin E acetate, which was linked to lung diseases that resulted in a string of hospitalizations and deaths in late 2019, prompting statements from the Centers for Disease Control.
The lack of regulation, lack of product disclosure, and ease of altering e-cigarettes means people may not know what is in them. Similarly, it was decades before the tobacco industry was forced to disclose the ingredients in its deadly cigarettes. This failure to disclose makes risk assessment by the average consumer, and particularly young people, and even researchers difficult.
4. Nicotine is More Dangerous for Young People.
Nicotine, whether smoked or vaped, presents a danger to the developing brain. Exposure to nicotine in adolescence can alter the brain, which continues to develop until the mid-20s.
E-cigarette companies also have continued the tobacco industry’s long tradition of targeting their marketing efforts at teens and young people. Advertising heavily on television and at point-of-sale retail, paying social media influencers, and creating kid-friendly flavors in high nicotine delivery products, e-cigarette companies have driven an increase in the number of teenagers exposed to nicotine.
5. Quitting Nicotine can be Hard – And Absolutely Worth It.
The best way to avoid nicotine addiction, is to never smoke, vape, or use other tobacco and nicotine products in the first place, particularly during childhood and adolescence when the brain is still developing. It’s important for parents to talk with their children about smoking and vaping. Ask open-ended questions like: What have you heard about vaping? How often do you see other kids vaping? What images do you see on social media? Be realistic about the risks. Vaping nicotine is less harmful than smoking cigarettes, but it doesn’t mean vaping is harmless, or easy to quit once started. Curiosity, experimentation, and fitting in with peers can quickly become a lifelong addiction with dangerous and costly consequences.
For those looking to quit smoking or vaping, or to support a loved one’s efforts, there are a number of great resources. Call 1-800-QUIT-NOW for quitting advice, referrals to local programs, and in some areas, free cessation medications. Visit the website Smokefree.gov for information, smartphone apps, chat, and text features to become free of tobacco products and vapes. The Truth Initiative offers a text-based quit-vaping program for teens, young adults, and parents with information at truthinitiative.org/quitecigarettes or text “DITCHJUUL” to 88709.