Vaping: The Great Innovation Public Health Failed to Embrace
Part I – Health Facts and Falsehoods: The Counter Narrative
After her recent provocative post on retooling our organ procurement system, Sally Satel MD is back with another piece encouraging you to rethink a common assumption. In a two-part Sensible Medicine post, Dr. Satel will argue that the use of electronic cigarettes should be welcomed as a disruptive public health innovation.
This topic has some similarities to her last. Is this an area where we are passing on a good solution because it is not a perfect one — even though we know the “perfect” solution is failing?
In part I, Dr. Satel reviews the facts about vaping and its use. In part 2, she will address the politics of vaping and the roots of opposition.
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Put aside everything you currently believe and think about the following paragraph, one which could appear in an article reflecting on the biggest healthcare innovations in the last 15 years.
Electronic cigarettes easily top the list of “disruptive technologies in public health.” In 2014, the Oxford English Dictionary christened "vape" the Word of the Year, a tribute to the impressive rise of the electronic cigarette, a battery-powered device that heats a flavored solution containing nicotine and converts it into an inhalable, or "vape-able," aerosol. Electronic cigarettes have become the most important tool in the battle against cigarette smoking since Surgeon General Luther Terry first warned of their risks in 1964.
And yet, today, instead of rejoicing at the promise of electronic cigarettes, health agencies have fueled a massive campaign of doubt regarding its health advantages to smokers. What are the facts and what explains the resistance to acknowledging the vast benefits of vaping?
Vaping is a form of harm-reduction. E-cigarettes are a replacement for cigarettes, which burn tobacco. The products of combustion – carcinogen-containing tar and other toxins and gases – cause lung disease and cancer and cardiovascular pathology.
As of 2021 (the latest year for which the CDC has figures) roughly 31 million adults, or 12.6% of Americans, smoked and about 12 million (4.7%) vaped.
What is known about the characteristics of e-cigarettes compared to cigarettes?
Foremost, the number of chemicals in cigarette smoke, greater than 7,000, exceeds that of e-cigarette aerosol by two orders of magnitude. In addition, though some toxins, including heavy metals, such as cadmium, lead, and nickel, may be present in e-cigarettes, they exist in trace amounts and in forms considered nontoxic. Roswell Park researchers found that levels of toxicants were 9–450 times lower than in cigarette smoke.
According to the Royal College of Physicians, the long-term health risks associated with e-cigarettes “are unlikely to exceed five percent of those associated with smoked tobacco products.” Public Health England, the equivalent of our CDC, puts the estimate “mostly below 1 percent and far below safety limits for occupational exposure.”
In a 2021 article entitled, “Balancing Consideration of the Risks and Benefits of E-Cigarettes,” 15 past presidents of the Society for Research on Nicotine and Tobacco document, among other things, that “tests of lung and vascular function indicate improvement in cigarette smokers who switch to e-cigarettes.” Findings show improvements in asthma and COPD and vascular function and hypertension in smokers who use e-cigarettes.
In summary, vaping is not safe, but it is at least 95 percent less harmful than smoking.
Not only are e-cigarettes safer, they are more acceptable than other alternatives to cigarettes. A greater percentage of smokers seeking to quit substituted e-cigarettes in place of the nicotine patch, nicotine gum, or other FDA-approved cessation aids, the CDC found.
E-cigarettes are also more effective than nicotine-replacement aids.
A year-long study appearing in the New England Journal of Medicine randomized almost 900 smokers to e-cigarettes or a combination of nicotine replacement methods, usually patches supplemented by nicotine chewing gum, mouth spray or inhalator. Those randomized to e-cigarettes were 80 percent more likely to achieve sustained abstinence from cigarettes for one year (18 percent), compared with those who used nicotine replacement therapies (9.9 percent).
A recent Cochrane Collaboration assessed the results of 78 studies that compared e-cigarettes with patches or gum, varenicline, e-cigarettes without nicotine, behavioral support, such as advice or counseling; or no support for stopping smoking. The report found “high certainty evidence that people are more likely to stop smoking for at least six months using nicotine e-cigarettes, or ‘vapes’, than using nicotine replacement therapies, such as patches and gums [and] may work better than no support, or behavioral support alone and they may not be associated with serious unwanted effects.”
There are no head to head trials comparing e-cigarettes to the medications we most commonly use to aid smoking cessation, varenicline and bupropion. Comparing efficacies from the studies quoted above and a recent meta-analysis, we’d expect that e-cigarettes would be among our most effective therapies. E-cigarettes are more desirable for most people than the other forms of treatment. In sum, e-cigarettes might carry certain health risks and continued surveillance is necessary, but they are likely to be among our most effective and efficacious tools for smoking cessation and pose considerably lower risks than cigarettes.
This might be a surprising statement considering recent claims of American health organizations?
Claim: The American Heart Association says, under the banner of “The Ugly Truth about Vaping,” that e-cigarette use “is a dangerous trend with real health risks.”
Claim: The American Lung Association warns about “evolving evidence about the health effects of e-cigarettes on the lungs.”
Reality: in smokers, the opposite is true.
Claim: The American Cancer Society tells the public that, “E-cigarettes should not be used to quit smoking”
Reality: see data presented above.
Because of assertions like these, along with uncertain language in other health communication about vaping, the public has a poor perception of e-cigarettes. When I tell my patients at a methadone clinic that they should switch to vaping if they cannot or don’t want to quit smoking, they look at me wide-eyed. These very patients, already engaging in one of the most successful forms of harm reduction – methadone instead of heroin and fentanyl – have been misled about another product that could save their lives.
Their disbelief is reflected in the HINTS surveys of the National Cancer Institute, which shows a worrisome trend from 2014, the first year of measurement, to the most recent 2020 data.
In 2014, only 5.8 percent of people rated e-cigarettes as “more harmful” or “much more harmful” than smoking. In 2020, 27.7 percent held that impression. In 2014, 6.4 percent deemed e-cigarettes “much less harmful,” but in 2020 only 2.6 percent said so.
From articles in academic journals, one might have the impression that e-cigarettes pose myriad harms. In virtually every instance, such papers contain significant problems in study design (see here for a partial list of “deficient and unreliable studies” compiled by Brad Rodu, Professor of Medicine at the University of Louisville.) Another review reported common methodological flaws in testing for metal contents in e-cigarettes aerosol.
A 2022 article called “Analysis of Common Methodological Flaws in the Highest Cited E-cigarette Epidemiology Research,” analyzed 24 studies to reveal numerous flaws.
For example, a 2019 study in the Journal of the American Heart Association (JAHA) purported to have established a link between vaping and myocardial infarction. One of its authors emphasized a causal relationship. In truth, the study was terribly flawed: the many subjects who suffered heart attacks did so before switching from smoking to vaping. After researchers at the University of Louisville exposed this defect, JAHA editors retracted the article.
In the second part of this post I will discuss the (debunked) claim that vaping poses a “gateway” to smoking for teens, a brief history of the distrust of tobacco harm reduction, the lop-sided risk communication mischaracterizing teen vaping at the expense of informing adults accurately, how anxiety over teens has shaped the FDA’s heavy-handed regulatory approach, smarter approaches deployed in the UK, and how Big Tobacco wins when adult smokers are scared away from vaping.
Sally Satel MD is a senior fellow at the American Enterprise Institute, a lecturer at Yale University School of Medicine. She does not receive any funding from manufacturers of vaping products.
I did my last residency journal club on the effects of taxes on smoking and vaping: https://onlinelibrary.wiley.com/doi/10.1111/add.16002
The article's conclusion was that increasing taxes on one of those things decreased use of the item which was taxed, but increased use of the other product (a substitution effect). That is to say, people picked smoking or vaping, whichever was cheaper, but they weren't dissuaded from tobacco use.
This supports the harm reduction argument. I might prefer that no one used tobacco, but that is a very difficult outcome to achieve.
I think sleep is an under-discussed problem with e-cigs.
While I totally grant that they are safer than cigarettes in all kinds of ways, I have seen more and more patients who wake up at night, sometimes multiple times, in order to vape. It has become an ingrained sleep association and I have little doubt this is a bigger issue than we realize if millions of people are doing it.
This gets into one of the big drawbacks of e-cigs, which is their ability to be used discretely, including taking a drag or two in the middle of the night without waking up your spouse with the smell of tobacco (a story I've heard innumerable times).
I was a smoker in college and quit when I realized I couldn't keep up the habit in medical school. One of the biggest aides in quitting smoking is the offensive smell of tobacco, the fact that it is obvious when you use it, and the difficulty of covering it up. If I had vapes in college I'm certain I would have continued using it straight into medical school. Maybe that would have been OK all things considered and wouldn't affect my health much (aside from increasing my concentration from the nicotine). But maybe it does? It just seems to be something worth considering.
If they haven't developed these already, I think it would be good to have self-tapering e-cigs for those who want to quit. Easy to program in dosing and number of puffs per hour or however you want to schedule it.