adult smokers

January 2020 has come and gone. Resolutions were set (and some broken). I suspect—given what we know about the effects of smoking—that somewhere among the estimated 34.2 million smokers in the US ^1,2  lie a few who resolved to shake the habit. Cigarette smoking is the leading cause of preventable disease and death in the United States accounting for more than 480,000 deaths every year (about 1 in 5 deaths).¹

But, What About Vaping?

In November 2019, the AHA launched its #quitlying campaign to address the youth vaping crisis. As an AHA Early Career blogger, I began to tweet (@DrAnikaLHines) what I was learning about vaping (a topic that I’ve otherwise not broached) from the 2019 Scientific Sessions:

• From 2017 to 2019, e-cigarette use among high school students increased by 135%³ (about 25% of high school students have “vaped” in the past 30 days).³ E-cigarette use tripled among middle school students—from 3.3% to 10.5%.³
• E-cigarette use drove a 59% increase in use of any tobacco product among high school students (from 19.6% in 2017 to 31.2% in 2018).³
• While more research is needed, the Surgeon General has concluded that several studies show E-cigarette use is “strongly associated” with the use of other tobacco products among youth and young adults, including conventional cigarettes.³
• Many questions remain about the long-term health effects of these products and their effectiveness in helping smokers quit.⁴
• The evidence is already clear that it is unsafe for young people to use e-cigarettes or any other product containing nicotine.⁴
• Some of the flavorings found in e-cigarettes have been shown to cause serious lung disease when inhaled.⁵

Well, fellow bloggers and I were met with backlash and cries of “vaping saved my life” and “vaping is harm reduction” and “vaping is promoted as a cessation technique in Europe” and my favorite—‘big heart, quit crying” by individual (adult) users and small retailers. As I mentioned before, I don’t research vaping, so I had no retort. I do, however, live in a department that happens to be seated in the hotbed of the tobacco discourse (Virginia) and jam-packed with researchers who have devoted their careers to cancer prevention and tobacco products. Literally! VCU has a Center for the Study of Tobacco Products. Here’s what I’ve learned about alternative tobacco products being used in Virginia (and nationally):

1. Not every vape is created the same. The two products at the core of discussion are e-cigarette and tobacco-heated products.¹⁰ E-cigarettes are battery-powered and heat liquid usually containing nicotine in order to produce an aerosol. There’s a wide variety of designs, electrical power, levels of nicotine delivery, and flavors.¹⁰ Devices include cig-a-like, refillable tank systems, and pod mod innovations. On the other hand, heated tobacco products (also electronic), heat tobacco to produce an aerosol containing nicotine.¹¹ (This is where tobacco giants like Phillip Morris have become involved, including their “I quit ordinary smoking” (IQOS) product approved for sale by the FDA in April 2019).¹⁰
2. Adult and youth reasons for use differ; so, there are separate sets of issues. Adults cite quitting/reducing smoking and health reasons for using e-cigarettes. Youth attribute their vaping to their social networks (friends and family who use them) and/or the availability of flavors.⁶ Data from 2013 indicated that 13.1% of high school e-cigarette users had never used another tobacco product.³ E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, including conventional cigarettes.^3,7,8
3. The long-term effects of alternative tobacco products in adult smokers, including e-cigarettes and heated tobacco products, remain unclear; however, preventing nicotine addiction among youth is a priority. Studies of the effectiveness of products as smoking cessation approaches are inconclusive. The Centers for Disease Control and Prevention says that e-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.⁴ Heated tobacco products, such as the IQOS device, have been linked to pulmonary disease and cancer, but not to the same extent as combustible products.⁹

Summary

We don’t know everything, but we know enough to say that vaping is not a “harmless” habit. It is not recommended for youth, young adults, pregnant women or adult non-smokers.⁴ Smokers who opt into e-cigarettes should know that there’s no guarantee that it will help them quit and that e-cigarettes bear their own risks of injury and mortality. E-cigarettes are not recommended as a smoking cessation aid. Further, a recent CDC study found that most adult e-cigarette users don’t stop using combustible products, but become “dual users”.¹¹

My Take

As I see it, the biggest issue is framing vaping as harmless. More alarming, is the interplay between peer influence and attractive flavoring that draws youth into a nicotine addiction long before their brains have the capacity to make an informed decision.

Vaper vapor, indeed.

References

1. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States, 2019.

2. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019, 68(45);1013-1019.

3. Campaign for Tobacco-Free Kids, “Electronic Cigarettes and Youth”, November 8, 2019 / Laura Bach. Accessed at: https://www.tobaccofreekids.org/assets/factsheets/0382.pdf

4. CDC, “Electronic Cigarettes.” https://www.cdc.gov/tobacco/basic_information/e-cigarettes/.

5. HHS, E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016, p 184.

6. Tsai J, Walton K, Coleman BN, et al. Reasons for electronic cigarette use among middle and high school students – National youth tobacco survey, United States, 2016. Morb Mortal Wkly Rep. 2018;67(6):196-200. doi:10.15585/mmwr.mm6706a5

7. Barrington-Trimis, JL, et al., “E-Cigarettes and Future Cigarette Use,” Pediatrics, 138(1), published online July 2016. Wills, TA, et al., “Ecigarette use is differentially related to smoking onset among lower risk adolescents,” Tobacco Control, published online August 19, 2016.

8. Berry, KM, et al., “Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US Youths,” JAMA Network Open, 2(2), published online February 1, 2019.

 9. Salman R, Talih S, El-Hage R, et al. Free-Base and Total Nicotine, Reactive Oxygen Species, and Carbonyl Emissions From IQOS, a Heated Tobacco Product. Nicotine Tob Res. 2019;21(9):1285-1288. doi:10.1093/ntr/nty23

10. Barnes AJ and Snell LM. Alternative Tobacco Products Use in Virginia. https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/VCU_eCig_10-19_F2.pdf

11. CDC, Electronic Cigarettes, What’s the Bottom Line? https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdf

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