Smoking cigarettes is the leading cause of preventable disease in the U.S. and the world. The CDC said while the percentage of adults who smoke cigarettes is at an all-time low, there are still an estimated 34 million adults who still smoke and are at risk of developing smoking-related diseases like cancer, heart disease, stroke coronary artery disease, and even Type 2 diabetes. Vaping products have been marketed as aids in smoking cessation, and there is some evidence that vaping can help. However, there are other studies that suggest vaping is also linked to smoking initiation and detrimental health effects.
In “Smoking cessation or initiation: The paradox of vaping” Mohammed Al-Hammdani and Eden Manly said the rapid expansion of the vaping market led many to question whether vaping assists in smoking cessation or paves the way for new smokers. They said health professionals tended to fall in one of two camps. “One that views it as a smoking cessation aid and another that perceives it as a risk for smoking initiation.” The opposing views lead to the public, especially smokers, being unsure whether vaping is safe for smoking cessation. They presented evidence for both views, but said the evidence for vaping as a smoking cessation tool is inconsistent; “however there is striking evidence that vaping is associated with a proliferation in the number of smokers, especially in youth.”
They cited a study showing that 21.8% of new smoking among youths between 12 and 15 was linked to prior vaping. Another study found that regardless of the intentions of the youths, e-cigarette users were 4.6 times more likely to use cigarettes and become tobacco smokers one year later. Further, a study of youths aged 12 to 17 found that current e-cigarette users were five times more likely to become cigarette users than non-current vapers. “Finally, Chaffee et al. (2018) found a positive correlation between ever e-cigarette use and combustible tobacco use among 12–17-year-old youth.”
Their review of the literature suggested the evidence was inconsistent for vaping as a method for smoking cessation. There was a study by Hajek et al that found that the 1-year abstinent rate was 18% in the e-cigarette group, compared to 9.9% in the nicotine-replacement group therapy (NRT). Among participants with 1-year abstinence, 80% of those who quit smoking using e-cigarettes continued to use them, compared to 9% of those who quit by using nicotine replacement therapy. Al-Hammdani and Manly thought this finding underscored how e-cigarettes sustained nicotine addiction relative to NRTs. “Contrary to the inconclusive evidence produced by studies looking at the association between e-cigarettes and smoking cessation, there is consistent evidence from various reviews and cohort studies that vaping products are implicated in smoking initiation.”
Hammdani and Manly acknowledged that smoking cigarettes was more harmful than vaping and has more negative consequences because of the number of chemicals inhaled from each product: “41 chemicals from e-cigarettes and 7000 chemicals from cigarettes.” While tobacco use kills an estimated 480,000 people in the US every year, data from the CDC showed in February 2020 that a total of 68 people died as a result of vaping. While many of the tobacco-related deaths were from prolonged use, the long-term effects of vaping are still unknown. “However, current evidence makes it clear that any potential smoking cessation benefit from vaping is likely to be offset by the positive link between vaping and smoking initiation, as the escalating rates of e-cigarette use are likely to reverse the decline in youth smoking rates.” Particularly in younger vapers, vaping is not benign.
Young Vapers and Adverse Health Effects
A 22-year-old man from North Dakota was admitted to a clinic complaining of stomach aches and low oxygen levels. He was initially diagnosed with influenza and double pneumonia, but his condition worsened and he was put on life support. Eventually, he underwent a double lung transplant when he was given a “one percent chance of survival” as a consequence of years of heavy vaping. He will not be able to smoke or drink alcohol again; and he will need another transplant later in life.
A 17-year-old high school cheerleader called her mother from cheerleading practice, suddenly unable to breathe. She had been secretly vaping for three years and developed bronchiolitis obliterans, known as “popcorn lung,” a rare chronic disease. It was first discovered in microwave popcorn plant workers who developed it from breathing in diacetyl, an artificial flavoring. But popcorn lung can also be caused by acetaldehyde, which is found in vape smoke. “The progressive disease causes shortness of breath, wheezing, and fatigue.”
The girl has a good prognosis because they caught her condition early, but popcorn lung is irreversible; “it can cause problems like cancer in the future.” She now relies on an inhaler to help with her breathing. Her mother said: “We don’t know the status of her lungs now. We still don’t know if there will be long-term effects.”
An 18-year-old Oklahoma girl was rushed to the hospital because she couldn’t breathe. Unknown to her parents, she had been vaping for six years. Her left lung collapsed and her lungs were covered in blisters. “She was put in a paralytic coma and placed on a ventilator.” Her parents were told to prepare for the worst; there was nothing more that they could do. “But 13 days later, Addie opened her eyes.”
Since then, Addie, 18, has graduated from high school. But other dreams were lost. A dedicated basketball player since the sixth grade, Addie had wanted to join a college team and hoped to be recruited for track. But competitive sports are no longer possible due to the lasting effects of her ordeal.
Before she was hospitalized, she ran track and colleges were talking to her track coach. She also loved basketball and wanted to play in college. “After I got out of the hospital, all of that was gone.” Now she speaks about her experience at school assemblies in Kansas and Oklahoma, telling kids not to vape. She says: “Don’t be stupid like me … “It’s really not worth it.”
See the following videos: “The health impacts of youth vaping” from PBS and “What Are the Health Risks of Vaping for Youth?” from the CDC.
Vaping’s Makeover
Juul was one of the earliest e-cigarettes, created by two graduates of Stanford’s design school. Released in 2015, it was minimal and discrete; perfect for vaping in class or school bathrooms. Its use took off among teens in 2018. In April of 2018 the FDA announced several actions the agency was taking actions to stop the youth use of tobacco products, particularly e-cigarettes, and especially Juul products. The FDA sent an official request to Juul Labs, requiring the company to submit documents so it could better understand the high rates of youth use and the particular youth appeal of Juul products.
The information we’re requesting includes: documents related to product marketing; research on the health, toxicological, behavioral or physiologic effects of the products, including youth initiation and use; whether certain product design features, ingredients or specifications appeal to different age groups; and youth-related adverse events and consumer complaints associated with the products. We don’t yet fully understand why these products are so popular among youth. But it’s imperative that we figure it out, and fast. These documents may help us get there.
The New York Times said Juul Labs was accused of marketing to minors soon after its product came to market. Eventually the company agreed to pay $400 million to settle claims its advertising targeted adolescents. Juul became “the poster child for all the ways the vaping industry went wrong.” Once a selling point, the sleek design of the device became associated with “flouting regulation and kicking off a scandal.” Newer e-cigarette companies wanted to distant themselves from the scandal and look of Juul.
When Karely Alcantara, 21, began vaping in high school, most of her friends used Juuls, which were easily concealed from teachers and family members. Today Ms. Alcantara, now a student at the University of Maryland, sees people treating Elf Bars as ubiquitous accessories. She spots them at bars, in the cafeteria at her student center, and on TikTok and Instagram.
While Juul was more about being discreet, now vapers want to show off. Elf Bars were highly visible in lower Manhattan. At an outdoor restaurant, a strawberry-mango Elf Bar sat next its owner’s coffee. Another person took a puff of a lemon-mint Elf Bar while waiting in line to enter the Supreme store. “On TikTok, videos tagged #elfbar have more than 2.5 billion views.” One young vaper thinks vaping has become part of the culture.
For previous articles on Juul and e-cigarettes, see “Juul and the Fight to Regulate Vaping,” “The Armageddon of Juul,” and “Juul is Not a Gem.”
