US authorities have blamed vaping for a rash of recent lung injuries and deaths thought to be linked to products that contain tetrahydrocannabinol (THC), the primary psychoactive ingredient in marijuana. At the same time, use of nicotine-based e-cigarettes, such as Juul, has skyrocketed among middle and high school students, placing them at risk of addiction and potential health harms. In response, states including Michigan, Massachusetts, Oregon and Montana have initiated bans on flavoured vaping products or all e-cigarettes. These distinct public health issues are often conflated, causing widespread confusion about e-cigarettes and their risks.
Myth No. 1: E-cigarettes are not regulated in the US.
Experts and activists urging government action on vaping sometimes imply that the industry has completely eluded oversight. “We must not stand by while e-cigarettes continue to go unregulated, ”said the president of the American Medical Association. “E-cigarettes are unregulated, which means that we don’t know what’s in them,” a Kansas state health official stated in a news release.
E-cigarettes are, in fact, regulated by the Food and Drug Administration. In 2016, a “deeming rule” granted the FDA regulatory authority over the products, and the agency immediately prohibited selling e-cigarettes to people under 18. E-cigarettes currently on the market are required to display a warning label stating that they contain nicotine, and their makers must submit ingredient lists to the FDA (though these lists are not available publicly).
It’s true that e-cigarettes are not well-regulated: Unauthorised products regularly enter the market, and underage sales too frequently occur in stores and online. Moreover, the government treats e-cigarettes like tobacco products, not pharmaceutical devices, so they escape the FDA’s “safe and effective” standard. The products containing THC thought to be responsible for the lung injury outbreak are not regulated by federal agencies, since marijuana is considered a Schedule I drug.
Myth No. 2: Vaping is as harmful as smoking cigarettes.
A growing number of Americans believe that vaping is as unhealthy as smoking, according to a Reuters poll last month. This impression is probably reinforced by the actions of retailers like Rite Aid, Walgreens, Walmart and Kroger, which have halted sales of e-cigarettes while continuing to sell traditional cigarettes and other tobacco products. And the New York Post warned that “Vaping might be more dangerous than smoking” while reporting on a 2018 study in the American Journal of Physiology.
That study’s investigators, though, concluded that their data “aligned with the evidence of the less toxic effect of e-cig vapour compared with tobacco smoke.” E-cigarettes are undeniably harmful, exposing users to numerous toxic and carcinogenic substances that may lead to adverse health effects. But they virtually eliminate exposure to carbon monoxide, tar and many of the 7,000 chemicals that contribute to cigarettes’ lethality. In the most comprehensive review of the health effects of e-cigarettes to date, the National Academies of Sciences, Engineering and Medicine found that completely switching from cigarettes to e-cigarettes lessens exposure to numerous toxins and carcinogens and probably reduces adverse health outcomes in several organ systems. This evidence was supported by a large national study finding that exclusive e-cigarette users had substantially fewer biomarkers of toxicant exposure, compared with smokers and users of both types of products. In short, e-cigarettes are less harmful than smoking, but are by no means safe.
In the recent THC-linked outbreak, every state but Alaska reported cases of acute injuries and even deaths from vaping. But smoking and exposure to second-hand smoke still cause 480,000 deaths in the United States each year, and according to the World Health Organisation, tobacco kills almost half of all long-term users.
Myth No. 3: Vaping causes ‘popcorn lung.’
The myth that e-cigarettes cause “popcorn lung” — a rare condition that can cause irreversible airway obstruction, resulting from severe damage to the bronchioles — originates from a 2016 Harvard study in which researchers detected the chemical diacetyl in a sample of vaping products. (The nickname stems from an outbreak among workers in a microwave-popcorn factory who were exposed to high levels of vaporised diacetyl, which is sometimes used to create butter-like flavours and is a known cause of the disease.) The authors did not explicitly link e-cigarette use to popcorn lung, but the possible connection has been highlighted by health organisations such as the American Lung Association (which published an article titled “Popcorn Lung: A Dangerous Risk of Flavoured E-Cigarettes”) and by outlets from Good Housekeeping to the New York Times. A former chair of the American Academy of Paediatrics Tobacco Consortium told the New Yorker that vaping can cause the disease.
Inhaled diacetyl and other chemical flavourants may certainly pose respiratory risks to e-cigarette users, but to date, vaping has not been linked to popcorn lung. Moreover, diacetyl is present in cigarette smoke at levels substantially higher than those measured in the Harvard study, but smoking has never been considered a risk factor for popcorn lung, making it extremely unlikely that e-cigarettes cause the disease.
Myth No. 4: E-cigarettes do not help people quit smoking.
American public health organisations generally discourage smokers from using e-cigarettes to help them quit. Smokefree.gov, run by the National Cancer Institute, nudges visitors toward other, FDA-approved methods for quitting smoking. California’s smoking-cessation website puts it more directly: “E-Cigarettes: Not a Quit Tool!” In March, a team of economists wrote in Barron’s that there was no evidence that “e-cigarettes were any better than self-help pamphlets” in helping people quit conventional cigarettes.
In Britain, however, nearly 900 smokers who wanted to quit participated in a recent randomised trial to determine the effectiveness of e-cigarettes compared with other nicotine replacement products, such as patches and gum. One year later, 18 per cent of the e-cigarette users were not smoking, compared with 10 per cent of the other nicotine replacement group. It is true that most smokers who try e-cigarettes continue to smoke, but that does not mean that e-cigarettes are an ineffective cessation aid: Most smokers who try FDA-approved nicotine replacement therapies also continue to smoke, but such products are still officially deemed “effective.”
We are still learning about the product features and behavioural factors that may contribute to successfully quitting with e-cigarettes. One national study found that more than 50 per cent of adult, daily e-cigarette users had quit smoking within the past five years, suggesting that the frequency of e-cigarette use may play a role in cessation.
Myth No. 5: E-cigarettes are a gateway to youth smoking.
After several longitudinal studies documented that youth who first used e-cigarettes were more likely to try cigarettes, publications such as Fortune claimed that there was a “gateway” effect. The FDA recently released a promotional video featuring magician Julius Dein transforming a vaping device into a cigarette and saying: “It’s not magic. It’s statistics.”
Despite their rigour, studies cannot fully account for “common liability” — the idea that certain people are simply more likely than others to engage in risky behaviours. Some youth may have tried smoking anyway; they just happened to use e-cigarettes first. It’s possible that e-cigarette addiction may cause some young people to migrate to cigarettes, but the order of product use does not alone prove cause. In ascertaining whether vaping has a “gateway effect,” it’s also important to consider magnitude: If e-cigarettes are strongly associated with subsequent smoking among youth, we might expect to see an uptick in smoking at the national level. But despite a 78 per cent increase in e-cigarette use among US high school students between 2017 and 2018, there was no statistically significant increase in the smoking rate, which this year has dropped to a projected historic low of 5.8 per cent.
One BMJ study that examined multiple sets of data on American youth tobacco use demonstrated that the decline in youth smoking rates actually accelerated as vaping became more widespread. Make no mistake, though: E-cigarettes do not seem to be leading large numbers of youth into smoking, but the strikingly high rates of teenage vaping alone are alarming.
— Washington Post
Daniel Giovenco is an assistant professor at Columbia University’s Mailman School of Public Health.