ADDICTION SCIENCE

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The word ‘vape’ was listed as the Oxford Dictionary’s word of the year in 2014. The definition of the verb means “to inhale and exhale the vapor produced by an electronic cigarette or similar device.” It’s been a decade since vape devices were introduced. The Centers for Disease Control and Prevention reports that electronic cigarettes are now used by almost 9 million US citizens.

Additional data from 2014 showed that about half of tobacco users (47-55%) have tried an e-cigarette. 22% of recent combustible cigarette smokers now use an e-cigarette. In looking at these numbers, it is fair to say that e-cigarettes and vaping are here to stay. This make it imperative that consumers understand the risk factors and medical data connected to vaping.

Core Differences Between Combustible and E-Cigarettes

E-cigarettes mimic traditional cigarettes but are more accurately described as nicotine delivery devices. Combustible cigarettes deliver smoke to the lungs whereas e-cigarettes aerosolize a nicotine solution into vapor. The nicotine itself is initially extracted from tobacco and then is blended in a solution containing two additional compounds, propylene glycol, and glycerin. Vaping involves exposure to fewer carcinogens than smoking by many orders of magnitude, and this is a reason why vaping may be a less harmful alternative than standard tobacco use.

One review article [1] that summarizes the literature regarding e-cigarette versus combustible cigarette compounds stated that e-cigarettes likely provide a harm reduction strategy to users via fewer inhaled carcinogens. Harm reduction themes involve strategies to diminish the danger or harm of substance use, while not necessarily decreasing the actual use itself. This article also reported that nicotine concentration seems to be comparable between smoked tobacco and e-cigarettes.

Vaping Toxicity

While there are fewer carcinogens in e-cigarettes, they are far from being toxicity-free. The CDC reports [2] that there may be additional hazardous compounds in the vaping chemicals such as diacetyl, nickel, tin, and lead. They also reviewed literature from other sources, including one paper which found that labeled nicotine levels on the products were not always accurate (Journal of International Drug Policy 2015).

It is also important to acknowledge that nicotine itself while being the addictive ingredient in both vaping and smoking, carries some health risks on its own. These include damage to a developing fetus in the case of pregnant mothers who use nicotine products. There is also some danger to the developing teenage brain from nicotine consumption.

Vaping as a Replacement Quit Strategy?

There are some similarities intrinsically between vaping and the use of nicotine replacement products such as nicotine lozenges, patches or gum. However, it is important to distinguish these groups. Multiple research trials have demonstrated the statistical efficacy of using nicotine replacement products to quit tobacco. This has not been thoroughly studied using vaping strategies either to quit tobacco or through using nicotine replacement products to quit the practice of vaping.

Of the current vaping research, one review article showed that e-cigarettes with nicotine were more effective than e-cigarettes without nicotine (placebo e-cigs) for helping people quit tobacco [3]. The final analysis described that the research quality of the findings would be characterized as ‘low,’ leading us to be hesitant when drawing firm conclusions from the research.

Craving Reduction Psychology

Another vaping research study analyzed some of the psychological factors connected to craving reduction via vaping[4]. This included using e-cigarettes and placebo e-cigarettes, showing a good reduction in cravings for each product. This suggests that the behavioral factors of holding a vape pen offer something independent of the actual nicotine. We talk about cues in the addiction cycle, and this is just one example of behavioral links to substance use.

One of the more comprehensive articles analyzing if users should use or not use e-cigarettes to help quit smoking was in the New England Journal of Medicine June 2016 [5]. This article presents two distinct opinions and cites the research on both sides of the argument. One opinion discusses that e-cigarettes are helpful as an augmented quit strategy and links evidence from the United Kingdom stating that vaping improved the odds of successfully quitting tobacco by about 60% as compared to using traditional nicotine replacement therapy or no replacement option.

Vaping Does Not Help

The alternative view cites evidence from numerous review articles showing that vaping did not help people quit tobacco. It reports that e-cigarette users had lower odds of successfully quitting than those who either used nicotine replacement or no support.

With this NEJM article, each physician delivered a strong opinion for tobacco users to fully quit and encouraged the practice of setting a dedicated quit date. While maintaining only a harm reduction strategy, there is a suspicion that the user may continually fall back on vaping as a ‘less guilty’ alternative than combustible cigarettes, possibly lessening the motivation to change.

Vaping and Youth

The CDC also reported recent vaping research data about middle school and high school usage of e-cigarettes. At this time, vaping seems to be more popular than combustible tobacco for youths. In 2016, 4.3% of middle school students and 11.3% of high school students reported vaping over the past 30 days. This amounts to over 2 million overall users.

Based on what we know about nicotine addictive risk, initiation of any nicotine use, especially for a youth, can carry insidious potential lifetime consequences depending on trajectory. For every new student who is trying the practice of vaping who otherwise wouldn’t have used tobacco, we suffer a blow from a public health perspective. Tobacco continues to be the number one preventable cause of death around the world. New nicotine users are at risk every day of developing a nicotine addiction, regardless of levels of carcinogens or the nature of vaping as a less harmful alternative than tobacco.

We do not know how many young e-cigarette users will transition to combustible cigarettes or live in an alternating fashion between vaping and tobacco. We have yet to do vaping research about comorbid conditions such as depression and anxiety. Both of these conditions are highly comorbid with teen smokers, hence we have some reason to believe that youths engaged in the practice of vaping may have such additional struggles at a higher rate than control groups.

Final Thoughts

Electronic cigarettes fill a complex middle ground in the discussion around nicotine addiction. While delivering a less-toxic alternative to consumers than combustible cigarettes, their use remains a health problem. For individuals in recovery, there is clear evidence that smoking cessation strengthens overall recovery rates as well as extends one’s life. Does switching to vaping suffice if you’re trying to make healthy changes? How should this be approached with young adults, especially those who are first-time users?

If you use an electronic cigarette, let your doctor know. Define your goals with nicotine, as this will help your provider know how best to help you. We use different strategies to help people cut back their use or to fully quit. We also use medication and therapeutic approaches to help those interesting in changing their patterns. This all begins with an in-depth discussion.

[1] Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes? – Cahn & Siegel. Feb 2011. Journal of Public Health Policy.

[2] CDC Guidelines Smoking and Tobacco Use https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm

[3] Hartmann-Boyce, J., Mcrobbie, H., Bullen, C., Begh, R., Stead, L. F., & Hajek, P. (2016). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, 2016(9). doi:10.1002/14651858.CD010216.pub3

[4] Bullen, C., McRobbie, H., Thornley, S., Glover, M., Lin, R. and Laugesen, M. (2010) Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: Randomised cross-over trial. Tobacco Control 19 (2): 98–103.

[5] Yeh, J. Bullen, C. “E-Cigarettes and Smoking Cessation.” New England Journal of Medicine. June 2016. 374: 2172-2174.

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