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Surgeon General Jerome M. Adams issued an advisory on December 18th, 2018 declaring E-cigarette use among youth to be an epidemic. Looking at the numbers Dr. Adams cites from the National Youth Tobacco Survey, it’s not hard to see why. According to Dr. Adams’s report, 1 in 5 high school students and 1 in 20 middle school students currently use E-cigarettes. That makes E-cigarettes about as popular among today’s teens as Fortnite; let that sink in. A lot of these E-cigarettes are appealing to high school students because they come in come in candy flavors, they don’t carry the same stigma as smoking, and it’s easy to get them hooked because they contain nicotine. It’s very easy for people to rationalize their vaping addiction because at least they aren’t smoking cigarettes. Today I want to explore the health risks of E-cigarettes, how E-cigarettes companies market themselves, and worrying trends in E-cigarettes.

Vaping vs. smoking, a false dichotomy

E-cigarettes started out being marketed as a “healthy” alternative to cigarettes when they hit the market in 2006. E-cigarettes are generally regarded as safer than traditional cigarettes but they have a lot of the same health risks, in addition risks of their own. Environmental Health Perspectives published a study in 2016 looking at the chemicals in the E-cigarette fluid, and of the 51 tested, 39 contained diacetyl. Diacetyl is a chemical flavoring typically used in popcorn as a butter-like flavoring. Diacetyl has been found to cause severe lung disease consistent with bronchiolitis obliterans in an investigation by the National Institute for Occupational Health and Safety. Bronchiolitis obliterans or “popcorn lung” causes irreversible lung damage, and can result in chronic cough and shortness of breath. Diacetyl isn’t the only chemical in E-cigarette vapor to be concerned about however.

The New England Journal of Medicine published a correspondence titled “Hidden Formaldehyde in E-Cigarette Aerosols” in 2015. What researchers found was that if the coil in the device overheats it can cause formaldehyde to be formed by the breakdown of propylene glycol. The researchers concluded that due to the increased inhaled formaldehyde intake the cancer risk could be as much as 5 times higher than the risk associated with long-term smoking. There was a significant limitation to the study however; their estimate was conservative because the researchers did not collect any gas-phase formaldehyde. According to the responses to the publication however, users should be able to detect the change because of an unpleasant burning taste described as a “dry puff”, and the risk of releasing formaldehyde was only associated with an overheated coil. I am unable to find any studies without serious conflicts of interest backing such a claim. I also found evidence that E-cigarettes can create formaldehyde emissions even through normal use according to a 2018 publication in Toxins .

E-cigarette also have risks that cigarettes don’t have such as device malfunctions; they can catch fire or explode. On February 4th, 2019 a Fort Worth man’s E-cigarette device exploded and dissected his left internal carotid artery, killing him. In 2018, a man in St. Petersburg, Florida was killed by a projectile wound to the head and burns covering 80% of his body when his E-cigarette exploded. A study published in The BMJ estimates that there were 2,035 E-cigarette explosion and burn injury related emergency department admissions between 2015 and 2017. While cigarettes are obvious fire hazards, I don’t recall any reports of deaths from exploding cigarettes recently.

The liquid used to refill E-cigarettes also presents significant health hazards not present in normal cigarettes. Nicotine can be absorbed transdermally, presenting a significant risk to children or pets if they were to come into contact with E-cigarette refill liquid. A lot of E-cigarette refill packages come in eyedropper-like packages, which are not childproof, and look like something in which you would store candy flavorings. In addition, lot of E-cigarette flavors come in sweet, fruit flavors that kids will want to get into. Poison control centers have handled over 3,000 E-cigarette-related cases in 2018.

E-cigarettes obviously contain nicotine, which is one of the most addictive drugs sold over-the-counter. Nicotine can harm the development of children’s brains, particularly the development of the cerebral cortex and hippocampus in adolescents. Nicotine exposure during pregnancy has also been shown to harm fetal brain development. Smokers who switch from tobacco to nicotine-replacement therapy may still be at significant risk for acute cardiovascular events compared to those trying to quit tobacco altogether. Even without all of the other chemicals in cigarettes, the nicotine in E-cigarettes can still presents serious health risks, especially to adolescents.

It can be argued that E-cigarettes are safer than traditional cigarettes because there are fewer harmful chemicals in the vapor compared to traditional cigarettes, but I think it’s a bit of a stupid question to ask which is safer. It’s like asking what kind of knife a serial killer is gonna use to carve out your eye balls; does it really matter? Not smoking or vaping is far healthier than doing either one. However, “It’s safer than smoking”, is the rationale that people will use to justify their habit. While research to analyze the long-term effects of E-cigarette use is on-going, the evidence we have now is more than enough to conclude E-cigarette use can have negative long-term health consequences. Why wouldn’t E-cigarettes have long-term health risks? When has recreationally inhaling a laundry list of chemicals on a regular basis ever gone well?

Harm reduction or gateway drug?

E-cigarettes companies still market their products as a safe alternative for smokers to switch to so they can quit entirely. However, the evidence shows that E-cigarettes aren’t a useful smoking cessation tool, and kids will readily switch from E-cigarettes to regular cigarettes. There is a large body of research examining if E-cigarettes help smokers quit; they don’t. A systematic review and meta-analysis published in The Lancet in 2016 reviewed 38 studies investigating if E-cigarettes could be used to aid smoking cessation. It found that the odds of someone quitting were 26% lower if they used E-cigarettes. It was also found that the odds of a smoker quitting if they switched to E-cigarettes were the same whether they intended to quit smoking or not. Despite the research clearly showing that E-cigarettes don’t work as a smoking cessation tool, E-cigarette companies will still market them as if they are.

More recent studies have been investigating whether or not E-cigarettes can act as a gateway to smoking in middle and high school students. A 2016 study in JAMA surveyed 3,396 high school students about their smoking habits. Students who stated that they vaped were twice as likely to start smoking, and their smoking habits reflected their vaping habits. The newest study published in JAMA on February 1st of this year used data from the Population of Tobacco and Health Study and follow-up surveys. Based on the 6,000 students surveyed it was found that prior E-cigarette use was associated with a three-times higher risk of cigarette use. The association between E-cigarette and later smoking was stronger in youth in the low-risk group. Vaping advocates online like to claim that E-cigarettes are hurting the tobacco industry. The reality is, E-cigarettes are helping to create a new generation of smokers.

Vape Nation

Tobacco use among children has been dropping steadily for close to four decades, until cigarette use among high school students jumped 1.6% from 2017 to 2018. It’s clear that the explosion of E-cigarette usage is the cause. But what caused the explosion in vaping? It all comes down to viral marketing, the most viewed videos that appear when searching vaping were created in the past two years exactly when the vaping trend began to take off. A lot of social media personalities, whose main audience is teenagers, vape on-stream or make vaping content. Vape companies know this and have tried to make deals with gaming streamers whose main audience is teens, whether they vape regularly on stream or not. Two popular Twitch.tv streamers, Gothalion and ProfessorBroman said on Twitter that vape companies contacted them about potentially promoting their products on stream. Both streamers are well known for being stand-up guys, and never would’ve taken such a deal. Other YouTubers, such as FaZe Rain, vape regularly and have made videos glorifying vaping, and the videos aren’t even age-gated by YouTube. I think it’s pretty clear that vaping didn’t start as a trend through television, movies, or news how we would typically expect trends like this to start. Vaping has been growing as a trend through social media sites like YouTube, Twitch, and Facebook. It’s important for parents to monitor what and who their kids are watching online. YouTubers and Twitch streamers have a lot of influence on kids. Understanding how vaping got to be such a big trend is important if we’re going to tackle this problem.

Worrying product trends

It’s interesting to browse vaping forums or listen to people talk about their vaping habits. Smokers typically stick to one particular brand of cigarettes and rarely switch. However, E-cigarette users have been shown to be more involved with their vaping habit, modifying product features or switching brands frequently. Just look at the difference in content between the smoking and vaping subreddits. It’s clear that the novelty of different vape products is a big selling point for vapers and they’re much more likely to use a variety of different flavors, brands, and even vape fluids with different drugs in them.

The buying habits of vapers isn’t just worrying because the chemicals in vape liquids vary from brand to brand, but vape companies make vape liquid with entirely different drugs in them. One company called InhaleHealth sells electronic cigarettes that allow users to take B12 and melatonin supplements through vaping. You might be thinking I just googled for hours to find the weirdest vape products I could find. I only know these exist because I’ve seen them sitting on the front counter at Sheetz for close to 6 months. There is no evidence that these products are more effective than just taking the associated dietary supplements, or that taking those supplements is necessary in the first place. It’s not just dietary supplements either; cannabis vapes are a growing trend where cannabis is legal. While it’s no surprise that people want to vape cannabis recreationally, companies are marketing CBD oil E-cigarettes as if they have health benefits. CBDOilReview.org claims:

Vaping CBD oil is one of the preferred methods to ease side effects of diseases, illnesses, and ailments including Leukemia, all types of Cancers, stress, anxiety, joint pain, seizures, inflammation, sleep apnea, high blood pressure and the list goes on. There are many benefits to CBD vape oil. However, the effectiveness of CBD helping with these conditions (and many others)

By their own admission, CBD oil has not been scientifically proven to treat any of those conditions. Who is CBD oil preferred by to treat those conditions? I would guess it’s the company selling CBD oil.

E-cigarette companies are big tobacco

E-cigarette companies are terrified of government regulation, whether it be safety regulations or laws that control where vapers are allowed to vape. Right-wing think tanks will criticize the FDA whenever they attempt to regulate the E-cigarette industry, claiming that regulations will do more harm than good. All of the arguments against regulation of the E-cigarette industry follow the same exact pattern. First, they will claim that E-cigarette usage hasn’t actually risen a significant level; which is obviously wrong. Then they will argue that regulations of the vaping industry claiming that it will increase smoking rates because E-cigarettes are an effective smoking cessation tool. Both claims are patently false, but it’s what lobbyists for the E-cigarette industry, which includes some doctors, will claim when talking to legislators.

Remember that response I talked about to the correspondence in the NEJM about formaldehyde in E-cigarette aerosols? There was a particularly interesting letter to the editor from Joel Nitzkin and Konstantinos Farsalinos in response. Both reported conflicts of interest in their letter to the editor. Farsalinos reported that that some of his studies on electronic cigarettes were performed with unrestricted funds provided to the Onassis Cardiac Surgery Center by FlavourArt and Nobacco, two E-cigarette companies. Dr. Nitzkin reported receiving partial funding for some of his tobacco policy work from the R Street Institute, an anti-regulation conservative think tank. Fortunately, in the conflicts of interest section neither had any more conflicts of interest to report; it’s hard to have more conflicts of interest than that.

In the letter, the two papers they cite are written by Farsalinos himself in the International Journal of Environmental Research and Public Health . That journal came up frequently when I was researching fake disorders for my Afflicted article; it’s a predatory journal. Farsalinos even has his own blog where he criticizes even the most well-designed studies as “research malpractice” when their findings show vaping isn’t safe. Dr. Stanton Glantz, director for the Center for Tobacco Research Control & Education, ripped apart both studies published by Farsalinos. Dr. Glantz compared Farsalinos’s research to earlier cigarette company-inspired studies that concluded it was toxicologically impossible for secondhand smoke to cause any disease. Despite the glaring conflict of interest issues, vaping websites will parrot Farsalino’s findings as if they are cutting-edge, scientific fact.

The main author of the response in the NEJM correspondence, Joel Nitzkin, also has a history of being cozy with the vape industry. Dr. Nitzkin has a long history of writing letters to state legislatures decrying proposed legislation that would regulate the vape industry. He argued that regulation would cause E-cigarette users to switch to traditional cigarettes, despite evidence to the contrary. Nitzkin even makes the ridiculous argument that tobacco control organizations are in partnership with the pharmaceuticals industry. His argument to legislators reads more like a sales pitch for E-cigarettes or a conspiracy theory on a vaping forum than a doctor trying to inform legislators about public health problems. As ridiculous an argument as it may seem, E-cigarette enthusiasts will argue online that any regulation imposed on the E-cigarette industry is a win for the tobacco industry, which is rather disingenuous. The argument implies that E-cigarette companies are somehow different from tobacco companies. The largest E-cigarette company, Juul, took a 12.8 billion dollar investment from Altria. Altria is a tobacco conglomerate that owns some brands you might have heard of such as Marlboro, Copenhagen, Skoal, and Middelton’s. Regulation of the E-cigarette industry is not a win for tobacco industry because E-cigarettes are not smoking cessation tools, and the E-cigarette industry is very much intertwined with the tobacco industry.

Conclusion: Scourge of the past

For the first time this century, underage cigarette usage is on the rise and it seems clear that the explosion of vaping is responsible. E-cigarettes are not an effective smoking cessation tool but they’re still marketed that way. E-cigarettes are probably healthier than cigarettes but they’re still not healthier than not using E-cigarettes or tobacco cigarettes. Public health organizations, regulatory agencies, and state governments are trying to take action, but they’re meeting substantial resistance from E-cigarette companies and their favorite doctors claiming that any action against the vape industry somehow benefits the tobacco industry. Fortunately, the government has been pretty on the ball. The Surgeon General has a great website where parents and teens can get the facts about E-cigarette use among teens and the risks. The FDA issued a final ruling in May of 2016 that deemed E-cigarettes and their accessories subject to regulation as tobacco products, and E-cigarette manufacturers were given a deadline to start complying with the new FDA regulations. Many of those regulations have come into effect over the past year, and there are many more about to come into effect this year. E-cigarette manufacturers are now required to submit a list of ingredients in their products, and sellers are not allowed to display advertisements for E-cigarette products without a warning label. Stores that modify E-cigarettes, or mix and prepare nicotine e-liquids may be considered manufacturers of tobacco products and subject to associated regulations.

That’s all great news but we still need to address the problem that these products still appeal to middle and high school students. The campaign against underage smoking has been undoubtedly one of the most successful public health campaigns of all time. From 1976 to 2015 the rate of smoking amongst 12th grade students dropped from 28.8% to 5.5%. Smoking went from being marketed as something only cool people do to being banned from advertising on television and radio outright, and found generally repulsive by most people. Vaping has managed to escape both the stigma and regulations around the tobacco industry and we need to fix that. E-cigarettes have a lot of the same risks as other tobacco products but none of the stigma. There have been a lot of good ads targeted at teens against vaping made by the FDA that get the salient points across quickly and clearly while presenting vaping in a negative light. However, some ads such as those from TobaccoFreeCA and TruthInitiative are not effective messaging, and almost amount to advertising for the vape industry. Effective messaging should talk about the health risks of vaping, including harming brain development, cardiovascular health, and addiction; not how popular vaping is in schools using weird puppet skits.

We need good messaging to win teens over because the vaping community has a lot of nonsense on the internet. For every action the FDA takes against the vaping epidemic, you can find a youtuber with at least one hundred thousand subscribers criticizing the FDA using the same nonsense arguments vape lobbyists use. Vaping is bad, kids. Anyone that says otherwise is wrong. The evidence shows that vaping won’t help smokers quit, but will help create new ones. Vaping might be healthier than smoking, but is nowhere near as healthy as not smoking or vaping. The vape industry is using the same slimy political tactics tobacco companies used in the past to promote their products to children and protect themselves from regulation. Hopefully we can get some progress on this issue so I won’t have to worry as much about someone assaulting my ears by vaping over Discord; that’s my last wish.