Traditional cigarettes are undeniably dangerous, and everyone knows it. Nearly 1 in 5 US deaths can be attributed to smoking, according to the Centers for Disease Control, including around 90% of all lung cancer deaths. Cigarettes don't just cause a litany of medical conditions, from cancer to coronary heart disease; they make other diseases worse, by weakening the immune system and harming nearly every organ in the body.
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Enter vaping. It simulates the experience of smoking, and often (but not always) delivers the addictive substance nicotine, but without the tar and combustion-created carbon monoxide that actually cause cancer. On the face of it, vaping sounds like a winning solution.
As of 2014, nearly 40 million American adults were still smoking. That number has been steadily declining for years, thanks to public health campaigns and stringent restrictions on cigarette advertising. The e-cig industry, on the other hand, hasn't had to deal with much red tape. And without regulation, e-cigarette manufacturers have been able to peddle their products in highly-flattering, and often unsubstantiated, ways.
In a review of 59 e-cig websites in 2011, researchers at the San Francisco Center for Tobacco Control and Research found that the vast majority of vape advertising used improved health as a key marketing message:
None of these claims have been adequately substantiated yet, although most researchers are in agreement that vaping is not as dangerous as smoking. But it's not healthy, either. If e-cigarettes have any benefit, it's as a way to get smokers to quit.
People smoke for lots of different reasons, but no one would deny that an addiction to nicotine is primary among them. One thing manufacturers consistently neglect to mention is that, where addiction is concerned, e-cigs and smoking are worlds apart.
Today, smokers can expect to absorb about 0.95 milligrams of nicotine for every cigarette, according to the CDC. Of course, there's no direct way of comparing a cigarette's nicotine content to vaping, and e-cig consumers have a wide array of nicotine levels to choose from. On the high-end, though, it seems from preliminary research that one puff of vapor will deliver about 35 micrograms, or 0.035 milligrams, of nicotine. That means you'd have to take about 27 puffs of vapor to equal one cigarette.
To get an equivalent nicotine fix, it's likely that the average smoker would have to take more puffs of vapor, and more consistently, than they would on a cigarette. While vapor is definitely less harmful than tobacco smoke, it's not good for you. Studies have shown that vapers are being exposed to many of the same toxic substances as smokers, including acetaldehyde, cadmium and lead, albeit at lower concentrations. But since e-cig users are probably exposing themselves to more vapor, substantial health risks may still be present.
In reality, existing smokers are often supplementing their combustible habit with e-cigarettes, rather than replacing it entirely. This is being called the "dual use effect," and it might be a problem. Speaking with Gizmodo in 2014, Dr. Stanton Glantz at the Center for Tobacco Control Research and Education said that "while a puff on an e-cigarette isn't as dangerous as a puff on a regular cigarette, the main effect they seem to be having is to keep people smoking cigarettes."
Other researchers haven't been so ambivalent. After a government agency determined e-cigarettes to be "95% less harmful than tobacco," England's national health insurer suggested that it would start covering the devices as smoking cessation aids.
When people talk about vaping as healthy, they usually do so in this context, as an alternative to the admittedly-deadly cigarette. There's an interesting dynamic here. Obviously, e-cigarettes are a threat to Big Tobacco, but they're also threatening the pharmaceutical industry, by offering a potential replacement to smoking cessation aids like Nicorette, a product marketed by both Johnson & Johnson and GlaxoSmithKline. Vapes are already cutting into the revenue streams feeding these companies. In a survey answered by 20,000 smokers trying to quit, 57% said they had used e-cigs over the last 12 months, while only 39% said they had used nicotine gums or patches. Another 39% reported being prescribed a pharmaceutical like Chantix.
Maybe Big Pharma should be scared. Early results have shown that e-cig use may substantially decrease smoking.
Between 2011 and 2013, Swiss researchers followed 367 vapers over the course of a year. Most of the study subjects were former smokers, and about three-fourths of them vaped daily. After one year, 89% of the daily vapers were still using e-cigarettes, and they were vaping at the same rate. Only 6% of the former smokers relapsed, returning to traditional cigarettes. But among dual users, people who were vaping and smoking daily, nearly half had quit smoking after one year of using e-cigs. So dual-use might actually be the key to implementing vapes as a smoking cessation aid.
Dual users who hadn't been able to quit entirely still saw benefits. On average, these people smoked 5.3 fewer cigarettes every day after a month of vaping. Interestingly, they didn't cut down even more over the course of a year. After one year, the dual users were still smoking only 5.3 fewer cigarettes than they had started out with. For these people, it looks like vaping only replaced a portion of their nicotine intake, but didn't reduce their overall dependence on the chemical.
In New Zealand, researchers at the University of Auckland looked at a different sub-population of smokers: people who actively want to quit. 657 current smokers were randomly placed in one of three groups, receiving either 16 mg nicotine e-cigarettes, nicotine patches or a "placebo" e-cig without any nicotine. The rest was simple. Follow the smokers to see if they turn back to traditional cigarettes.
It should be noted from the outset that "abstinence," staying off cigarettes, was far less common than the researchers had expected, no matter which cessation aid (or placebo) a smoker had been given. In fact, the abstinence rates were so low that the team wasn't able to derive any significant conclusions about which quitting method was more effective.
With that being said, smokers who switched to a nicotine-containing e-cigarette did stay off cigarettes more. After six months, 7.3% of the people who were using e-cigs with nicotine had stayed away from combustible smokes, while 5.8% of the people who had been using patches did. As you would expect with a chemical dependency, placebos weren't particularly effective, with only 4.1% of the sham e-cig users remaining abstinent.
Despite the rather low abstinence numbers for the placebo group, the researchers concluded that "e-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches." In a 2013 study conducted in Italy, researchers found a similar result. The team provided 300 smokers (who were not intending to quit) either:
After 12 weeks, around 22% of the smokers had reduced their tobacco consumption, while about 11% had quit entirely. Most importantly, there were "no consistent differences" between the study groups, the scientists wrote in the American Journal of Preventive Medicine. Smokers who received an e-cig without nicotine were just as apt to quit smoking as those who were given 7.2 mg e-cigarettes.
Some surveys have shown similar positive results. In the UK, a survey of almost 6,000 smokers trying to quit found that e-cig users were about 63% more likely to report abstinence than people using over-the-counter patches or gums alone.
Here in America, however, a two-year series of surveys involving 949 smokers found that whether or not a person had been using e-cigs didn't affect how likely they were to quit, or how motivated they were about quitting. Interestingly, e-cig users also reported preferences associated with greater levels of nicotine dependence, like wanting a cigarette within 30 minutes of waking up, than smokers who didn't use e-cigarettes. This likely supports the idea that many smokers adopt e-cigarettes as a way of supplementing their nicotine addictions, rather than weaning themselves off nicotine.
Using data collected from state-run tobacco quitlines, smoking-cessation experts from Seattle's Alere Wellbeing (now owned by Optum, a subsidiary of UnitedHealthcare) found that while smokers most frequently cited a desire to quit smoking as their reason for trying e-cigs, e-cigarette users were actually less likely to quit than people who had never tried them.
Writing in the journal Addiction, public health researchers from Brown and Boston University put their own tentative stamp of approval on vaping. Citing evidence that e-cig use reduced the perception of nicotine cravings in active smokers, and a clinical trial that found smokers who were told to use vaporizers came out more motivated to quit smoking, the authors concluded that "e-cigarettes offer more promise than peril." But their endorsement came with a caveat. Unless e-cigs are regulated, the potential benefit of each product is likely to vary.
Today, regulation is inevitable. On May 5, 2016, the US Food & Drug Administration announced that it would be regulating all vape products just like traditional tobacco products, which may be a sign that the FDA is preparing to endorse e-cigs as a legitimate smoking cessation aid. Or not. Smaller e-cig manufacturers have decried the FDA's new powers as a power-grab helmed by Big Tobacco, since steep regulatory fees may put all but the likes of RJ Reynolds out of business.
One thing, however, is certain. With regulation will come standardization, with more rigorous controls placed on both the contents of eLiquid and vaporizing devices themselves, which have shown a troubling penchant for blowing up at a moment's notice. That may be the first step in figuring out if, and how, vaporizing may hold benefits for current smokers.
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Thanks to our friends at Bompadre Law, Pennsylvania criminal law attorneys, for their contributions to this post.