Electronic cigarettes have experienced a sharp rise in popularity since first hitting the market back in 2007. Assigned a myriad of monikers like vape, pipe and mod, they’ve spawned sub-cultures, slang terminology and drawn celebrity advocates who cast them as desirable fashion accessories. But Jamal doesn’t care that Justin Bieber has a vape. He’s in it, he says, for the “cloud chasing” – the process of blowing large clouds of vapour to form complex shapes like rings, spheres, streams and ripples. It’s this craze that has prompted Jamal to tinker with the settings on his e-cigarette to encourage a thicker plume of smoke. He says he’s been trying to perform a ‘French inhale’ for weeks, a trick involving blowing smoke out of your mouth while simultaneously sucking it back in through your nose. It’s impressive, trust me. But here’s the thing. As pretty as that wispy plume might appear, the question that’s increasingly being asked is whether vaping is little more than a fancy delivery system – a smokescreen even – for a cocktail of potentially lethal chemicals that can wreak havoc on your respiratory system? After all, where there’s smoke, there’s generally fire.
Why is everyone talking about vaping right now?
You’ve probably heard the reports on vaping related deaths coming out of the US in recent months. Researchers there are investigating more than 1300 cases of lung disease and respiratory failure across North America, including 33 deaths, reportedly linked to e-cigarette use. At least 20 countries to date have outlawed the sale of vaping products including Argentina, Brazil, India, Mexico, Thailand, Singapore and Vietnam. The likes of Australia, Canada, Hong Kong, Norway and Japan haven’t outlawed them entirely but they are restricted. The Trump White House, meanwhile, has indicated that a ban on flavoured e-cigarette products in the US is imminent. The Australian Medical Association also has “concerns” over the marketing and advertising of e-cigarettes and has suggested the products “be subject to the same restrictions as cigarettes”. The Public Health Association of Australia has implored the government to use “precautionary principles” to reduce the chance of more people like Jamal taking up e-cigarettes as a fashion accessory or hobby. But although the concern is widespread, it’s not uniform.
There are some respected medical professionals who believe e-cigarettes are being subjected to an undue moral panic inflated by a hysterical media. Dr Lion Shahab, an associate professor in health psychology at University College London admits that while e-cigarettes are not totally harmless, they could offer a legitimate route to improving public health. Having spent the past 15 years studying the effects of tobacco smoking and more recently e-cigarettes, he believes the current demonising of the latter is unwarranted. Shahab, who’s been published in over 100 peer-reviewed papers and has extensive experience in the area, told MH his research on e-cigarettes found they deliver a “60-97 per cent reduction in the level of harmful toxicants and carcinogens when compared to cigarettes”. He adds that diseases related to cigarette smoking take 20-40 years to develop and that scientists are now looking at characteristics (or biomarkers) present in both traditional cigarettes and e-cigarettes to better predict long term health effects.
“Cigarettes contain 600-700 constituents and over 7000 chemicals, 70 of which are carcinogenic,” says Shahab. “E-cigarettes by contrast have few; primarily nicotine, chemicals to dissolve the nicotine and flavourings. It suggests that e-cigarettes are a less harmful alternative to cigarettes.” E-cigarette deaths should be viewed in context, Shahab adds. “Thirty or so people have died using e-cigarette products this year,” he says. “In the same time 75,000-plus have died in the US from smoking-related illnesses. We need some perspective.”
So... are e-cigarettes healthier than smoking?
It’s the purported hard and fast adoption of e-cigarettes among young people such as Jamal and his pals that has put the products in the spotlight. In September the US Food and Drug Administration (FDA) issued a stern warning letter to Juul Labs Inc., the maker of one of the most popular brands of e-cigarettes, for engaging in sketchy marketing practices targeting “students”. The FDA took particular issue with the company’s claims that its product is less harmful than cigarettes. The thing is, it just might be. Shahab says much of the data around vaping has been overstated. He cites figures showing regular e-cigarette users who didn’t previously smoke equate to just 0.1 per cent of vapers in the UK.
“If you look at the data in the US the number is still very small, around one per cent,” he adds. “What is often reported is the number of people who have used e-cigarettes in the past 30 days. If you drill down into some of the data, 60 per cent of teens say they have used e-cigarettes for less than 10 days in their life. The measurements are incorrectly presented. The vast majority of young people using e-cigarettes were smokers.” There are many health professionals, including Shahab, who advocate e-cigarettes as a healthier alternative to cigarettes. Ironically tobacco-based cigarettes are still legal in all of the 20-plus countries that have now completely banned the sale of e-cigarettes, except for Bhutan, which remains the only country in the world to have outlawed tobacco products. Brands are also throwing their weight behind the smoking cessation argument.
Juul claims its mission is “to improve the lives of the world’s one billion adult smokers”. Aspire, another manufacturer, recently described calls for strict regulation and/or a complete ban as “draconian” and proposes that the risk is “what you vape” not vaping itself. “It would be unfair to blame the entire alcohol industry for yearly onsets of methanol poisoning caused by black-market distillates,” a company spokesperson said. Shahab concedes that black market products pose a danger but notes that the recent spate of e-cigarette lung-disease cases is a phenomenon not seen outside of North America.
“Many of the people who died were found to have contracted lung disease and to have purchased bootlegged products that contain THC cannabis oil,” he says. According to the Centers for Disease Control (CDC), nearly 80 per cent of patients with ‘EVALI’ (e-cigarette or vaping product use-associated lung illness) reported using THC e-cigarettes. These products, Shahab says, require additional oil-based chemicals in order to dissolve the THC. “If incorrect solvents are used then theoretically users could inhale these oils into their lungs, which are harmful.”
Nicotine e-liquids are not available for sale in Australia, meaning Australians have to look elsewhere to procure them. Eugene, a 29-year-old from Sydney, is one of the vast majority of e-cigarette users who were former cigarette smokers. He says he made the switch to his mango and berry flavoured e-liquid two years ago and gets around the importation restrictions by carrying it in from the UK. Jimmy, 30, from Sydney, sources his Juul pods from an under-the-counter source in the city’s eastern suburbs and says that although he isn’t “unconcerned” about the health risks, he considers it better than smoking. Dr Rob Grenfell, Health and Biosecurity Director for the CSIRO, acknowledges the danger of bootlegged products in Australia. “While it is illegal to sell e-liquids containing nicotine in Australia, there have been many cases where these liquids, many of which were imported from overseas, have been found to contain nicotine and other unknown and dangerous ingredients,” he says, adding that exploding devices and ingestion of e-liquids are of “serious concern”.
But Shahab believes anything is better than burning tobacco and that e-cigarettes, when regulated and controlled, will improve public health outcomes over time. “Studies show that earlier versions of e-cigarettes were found to be as effective as existing quit therapies like patches and gum,” he explains. “A study published earlier this year in the Journal of Medicine showed newer models, which are more effective at delivering nicotine, increase cessation after 12 months by 70 per cent compared to nicotine replacement therapies.” For every one per cent increase in the number of people who use e-cigarettes there was a 0.5 per cent increase in the number of people who stopped smoking cigarettes, he adds. “As a population trend that shows a correlation between e-cigarette use and quitting cigarettes.”
Are e-cigarettes the lesser of two evils?
Not everyone is buying the e-cigarettes as-cessation-aid argument. When asked if e-cigarette manufacturers are right to claim their products help people quit smoking, Simon Chapman, emeritus professor at the Sydney School of Public Health, cites a recent study from New Zealand. There, among test subjects given a mixture of aids, including e-cigarettes, almost all were still smoking six months later, he says.
“I cannot think of any prescribed drug used for any condition where the condition persisted after six months of use for 93 per cent of users, and where anything but the language of failure would be used about such an outcome,” Chapman says. But for Aiden, a 29-year-old operations manager from Sydney, e-cigarettes did help him quit his 20-a-day, 12-year habit. He cites concerns about his health and the rising cost of tobacco as the main reason for his switch to electronic darts. He acknowledges he still worries about the effect his 500 puff-a-day habit (his e-cig has a counter) is having on his body, but it’s a risk he’s willing to take as it hasn’t obviously impacted his health, or indeed, his fitness.
“I have never felt healthier in the last two years,” he says. “Since quitting cigarettes, I have completed three marathons, countless half marathons, one half Ironman and I’m training for a full Ironman. When I smoked cigarettes I couldn’t run 250 metres without having to stop.” Shahab believes standardising and regulating e-cigarettes will help ensure men like Aiden have a better chance at quitting smoking.
“I think the UK has got it right,” he says. “E-cigarettes are endorsed by the National Health Service as a cessation product to be used to stop smoking. Regulation should ensure they are used and perceived as such.” Grenfell advocates a cautious approach to reduce the dangers of e-cigarettes. “Continued oversight, monitoring and regulation is needed to reduce the risk of serious injury from explosions and ingestion of e-cigarette fluids,” he says. But he remains more concerned by the dangers of tobacco, noting that while smoking rates have been declining since 1945, 14 per cent of adults still smoke with harmful consequences. “Smoking-related illnesses remain a significant cause of death and disability in Australia,” he says. Cloud-chasing Jamal is a rare example of a young adult who didn’t previously smoke but now vapes.
The truth is, while a growing body of research supports government concern about the risks of long-term damage to users, there is an argument that through careful regulation and use as a cessation aid, e-cigarettes are the lesser of two evils. Shahab believes media and health bodies have a responsibility to put the spotlight back on tobacco. “It’s hard to make a product as dangerous as a cigarette,” he says. “They kill over 50 per cent of users over time. It’s a complete travesty they’re still available when something less harmful is being banned.”