Science Friday
Hosted by Ira Flatow
Some research shows that e-cigarettes can be a useful tool for quitting cigarettes, but that strategy is hotly contested by scientists.
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This is Science Friday. I'm Ira Flatow. You've likely heard about the harms of vaping, but is it better for you than smoking?
The evidence is really clear that if you're comparing smoking to a licensed nicotine containing e-cigarette, the e-cigarette is going to bring much, much less risk to you.
The harms of smoking cigarettes are pretty clear. It's the leading cause of preventable death in the United States. It causes cancer, heart disease, lung disease. But when it comes to vaping or e-cigarettes, the risks are a bit more tricky to figure out. And the outbreak of e-cigarette or vaping use associated lung injury, IVALI, in 2019 and 2020, made things even more confusing. The founders of Juul, the company that popularized vaping, said they wanted to help people kick their smoking habits. But can vapes really help people quit? And how bad are they for you, really? And if you're addicted to vaping, how can you kick the habit?
Joining me now to answer those questions and more is one of the top researchers in the field, Dr. Jamie Hartman-Boyce, Assistant Professor of Health Policy and Management, University of Massachusetts in Amherst. Welcome to Science Friday.
Thank you so much. It's great to be here.
Nice to have you. Let's jump right in now. When most people think about the harms of vaping, they're probably thinking of IVALI or the outbreak a few years ago. Thousands of young people ended up in the hospital, as we all know. Can you give us a refresher on what was causing that illness?
Absolutely. So, one of the scary things about that illness is when it first started, no one really knew what was causing it, other than that it was following the use of e-cigarettes or following vaping. Over time, after a lot of investigation, it was linked back to an additive in some e-liquids called vitamin E acetate. That is something that we absolutely know should never be inhaled, but it was put in e-cigarette cartridges to make them look like they contained more THC than they actually did. And that was what was causing all of that illness.
Is that gone now?
That is gone now for the most part. We know that it makes people sick, but to be fair, we knew that it would make people sick before Avoli started as well. So what we have now are more careful checks on e-liquids, particularly if they're sold in states where marijuana is legal and people are buying them from dispensaries. But there's still always a risk if you're getting an e-cigarette from a source like your neighbor's garage, that it could have something in it that would make you really sick.
Yeah, I certainly see why. Let's say, though, that you're buying licensed vapes that don't contain vitamin E acetate. What are the health risks here?
It's a great question, and there's a number of complexities around it, which make it hard to give one clear answer. When it comes to a nicotine-containing e-cigarette that is authorized for marketing and sale by the US Food and Drug Administration, those products have been really extensively tested, and they've found, though not to be risk-free, to be substantially less harmful than something like smoking. However, vaping hasn't been around for all of that long. So in terms of the research on what's going to happen when people have vaped for decades, we're still waiting to see. And also, it's going to vary a lot based on the type of device you're using and based on what you're vaping. As we saw in Avoli, what goes into your e-cigarette has a huge impact on whether or not it's going to harm your health.
Because the vape still contains nicotine, right?
That's right. So nicotine has a very bad name, for good reason. It's the thing that's been getting people addicted to smoking for hundreds and hundreds of years. But nicotine in and of itself is not the thing that causes the cancer, the respiratory problems, the heart disease that we associate with smoking. Those are caused by the burning of the tobacco in a cigarette, and the nicotine is what keeps us coming back for more. So nicotine in and of itself, in reasonable doses, like you might get in a patch or a gum, has been proven to be pretty safe.
Is there different data for people who vape cannabis versus who vape tobacco?
It is such an important issue and one that I think the scientific literature has not done a good job on. Often, the surveys that get asked and the studies that screen people in ask if people vape, but they don't ask them what they're vaping. And that's really essential because we know what you're vaping is going to affect the health risks that come with it. The other thing that plays into this is that sometimes people who vape don't know what they're vaping, and we need more awareness around that, too.
We've all read about the alarming number of teens who are vaping. Are they, because of their age, more at risk?
Yeah, they are more at risk. I mean, first of all, teens in general might be more likely to use products that are not regulated, and they might be coming from sources where they're not kind of as established in their testing in terms of what's in there. We also know that, of course, the adolescent brain is very different from the adult brain. And so one of the real concerns about teen vaping, when it comes to nicotine, is that it's establishing a new addiction to nicotine. And we know that addictions in general are things that can cause a lot of harm to us. They can cost a lot of money. They can disrupt our lives.
Is it possible to compare the risk of smoking traditional cigarettes to e-cigarettes?
Absolutely possible to compare, and many people have done that. So the evidence is really clear that if you're comparing smoking to a licensed nicotine-containing e-cigarette, the e-cigarette is going to bring much, much less risk to you. E-cigarettes do not contain many of the toxic substances that are contained in cigarettes. And they also, when you vape, you're not burning anything. And we know that a lot of the harm that comes from smoking is coming from the burning. E-cigarettes were originally invented as a way to try and reduce the harm from inhaling nicotine.
But to be clear on this, based on the research, can we definitely say that vaping is less harmful than cigarettes?
We can. It depends what you're vaping, of course, right? So if you're vaping something with vitamin E acetate, no. If you're vaping a licensed nicotine-containing e-cigarette, yes, we can say that. There are dozens of randomized controlled trials, which are really high-quality ways to test the effects of an intervention. And those show that people who switch from smoking to exclusively vaping reduce their health risks.
You know, I think that's something that really gets lost in the conversation around vaping, doesn't it?
Absolutely.
Now, why do you think that is?
I think there are a whole host of things that play into that. One of them is, of course, that there is very genuine concern that any positive or reassuring messaging around vaping in people who smoke could make it more likely that people who don't smoke, and particularly young people, might take up vaping. So that's a real concern that comes into play. We've also, for decades and decades, and are still in a position in the US where the majority of people, including the majority of physicians, think that nicotine is the harmful substance in cigarettes. And that means that if people are vaping nicotine, we assume that they're also going to be equally as harmful.
Let's talk about that just in a little bit more of detail because I noticed when you're vaping, you're also heating up the substance too, right? Why is that different than burning it like smoking?
Absolutely. So in smoking, you are essentially creating fire, right? You're lighting it with a match or a lighter, and combustion is happening, that chemical process that releases all sorts of nasty things. When you're vaping, you're not burning anything. You're heating up a liquid which is turning into a vapor. But that's a very different process chemically than what happens if you're actually burning tobacco leaf.
We have to take a quick break, but don't go away. More on this when we come back.
If what you're concerned about is the addiction to nicotine, switching to a nicotine e-cigarette is not going to get rid of that.
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Let's get down now to the big question here, and that is, how useful are e-cigarettes as a smoking cessation tool as compared to, let's say, other methods?
So it's a great question. The studies of nicotine e-cigarettes for smoking cessation are generally very promising. They show on average that nicotine e-cigarettes help more people quit smoking than nicotine replacement therapies like patches or gums or lozenges. There have been fewer studies that compare nicotine e-cigarettes to some of the medications that can be used for smoking cessation. There's a drug called Varenicline, which is one of the best available ways to help people quit smoking. The evidence we have can't really differentiate between the two in terms of effectiveness, but we hope more studies will give us some clearer answers on that.
You know, there's always this aura about taking a puff, inhaling a cigarette, you know. Is there something about the action of inhaling a vape mimicking the pleasure of a cigarette that is uniquely helpful to aid people to quit smoking?
That's a great question. It depends on the person, but we absolutely know for a lot of people, those kind of behavioral, psychological, social cues that we associate with smoking, whether it be the visual image of the smoke coming out of your mouth, something that's called a throat hit, which is that feeling when it hits the back of your throat, or just an excuse to step outside during work, or if you're out with friends, to go into a smoking area. All of those really reinforce addiction to smoking. And when nicotine e-cigarettes first came out, scientists in the smoking cessation area were excited because all of a sudden there was something that could mimic a lot of those behaviors, the sociology and psychology of smoking, without causing as much harm.
Hmm. There's some research suggesting that many smokers who are trying to quit will smoke regular cigarettes and also vape. How should we understand this data?
So that's a phenomenon called dual use. People are both smoking and they're vaping as well. And there are different takes on this. There's absolutely justifiable concern that people could be increasing their risk by doing that. But there's also data that shows that if you give people who smoke an e-cigarette with the instruction that they're using it to reduce or help them quit smoking entirely, even if they end up smoking some, they end up smoking less than they were at the start. And we see reduced markers of risk in those people. There are also people who essentially find that they need to dual use for a long time before they can switch completely to vaping.
So it's still like a, it's like a bridge then.
Exactly. It can be a bridge out.
Yeah. Now, as we discussed, the science seems to bank e-cigarettes as an effective tool to help people quit smoking, but there is still quite a bit of disagreement about this among researchers, isn't there?
There is. It remains a contentious topic. When you kind of dig into it, a lot of that disagreement isn't about the question of whether or not nicotine e-cigarettes help people quit smoking. We have good evidence that they do. The concerns are more about if they're available to help people quit smoking, what's going to happen if people who don't smoke, particularly kids, start using them. Also, what are the longer term harms of vaping? And also, do you think the concern about smoking is ultimately the health harms from smoking? Or the addiction to nicotine? And if what you're concerned about is the addiction to nicotine, switching to a nicotine e-cigarette is not going to get rid of that.
Yeah, I think there's also a little bit of distrust, perhaps, of the tobacco industry.
Yeah.
Right? Which has now gotten into e-cigarettes.
Absolutely. So when e-cigarettes first came out and kind of we first became aware of them and they were being commercially marketed, they weren't being manufactured by the tobacco industry. But the tobacco industry has taken over a lot of our major e-cigarette brands, has a big share of the market, and that is an understandable and justifiable concern. You know, there are decades of history here.
Yeah. But you still come down on the public health side of this, that the benefit is clear to vaping.
Where I come down on it always is that I'm driven by the evidence, right? So I look at what the evidence shows and make my decisions based on that. And I think the evidence is really clear that for people who smoke, switching to e-cigarettes can help them quit smoking completely and improve their chances of living a longer, happier, healthier life.
Hmm. Would you go as far as to say that we should recommend people use e-cigarettes to help them quit?
I think the language that a lot of people use, which I quite like, is individualistic to the person in front of them. So if you are someone who smokes, who wants to quit, and you've never tried, for example, nicotine patches, or gums, or Varenicline, you have access to those things. We have a lot more research and a lot more safety data on those. So trying those first is probably a good idea. If however, you're someone who smokes, and you've used those before, they haven't worked, or you have no interest in using them, or can't access them, then thinking about going and trying a licensed nicotine-containing e-cigarette is certainly something the evidence would support.
Well, then would it be good health policy to prevent teens from picking up vaping? Or would that be better than them picking up cigarettes? I mean, how do you balance the risk and the benefits here?
That is something that is heavily debated in the circles that I'm part of. So ideally, we don't want young people using any form of nicotine. We don't want them vaping. We don't want them smoking. And my take on it, based on the evidence, based on the fact that we know the really enormous health harms that come from smoking, is that we certainly shouldn't discourage vaping more than we discourage smoking. We want to be really clear that smoking is incredibly harmful. If you don't smoke, you also shouldn't vape. And I think policies that confuse that issue can confuse the public. And there's some evidence to suggest that sometimes that can result in maybe more youth smoking than we'd see otherwise. And anything that increases youth smoking is a public health loss.
Yeah. Now, I know a lot of people have talked about how hard it is to quit vaping. And I understand that this has been a focus of your research lately. What have you found? What's most effective?
That's right. So this is a really new area of research. And we set out recently to review everything that have been published so far on the ways to help people quit vaping. There's not that much to say right now. We don't have that many studies that are completed. Those that are are fairly small. There are loads of studies in the pipeline. So all of a sudden, as a research area, this has really exploded. But what the evidence does show us so far are that the interventions with the most promise are a text message-based intervention in young people.
That absolutely shown increase in people successfully quitting vaping. We don't know if the same would happen with other text message based interventions or in older people. So kind of jury's still out on some of those other areas. And there was also some promising evidence for the medication Verenaclean, which is available on prescription as a stop smoking medication. And in an early trial, results were promising for vaping cessation as well.
Let me wrap up by asking you what you think is the biggest misconception about vaping.
I think the biggest misconception is that it is as or more dangerous than smoking. So I started working in vaping research back in 2014. And every year we find more and more studies that show that nicotine vaping still carries risks, but is much less risky than smoking. At the same time, public perceptions go the opposite way. So over time, more and more people believe that vaping is as riskier or riskier than smoking. And that's a really big problem if you're someone who smokes.
Right. Well, let me give you the blank check question I give a lot of my researchers because they don't ever have enough money.
If you had, if you had all the money in the world, what are the questions in the data that you would like to answer that we still don't have answers to that might be helped by this blank check?
Yeah. Oh, what a nice thought. So what I think we really need to do is, this sounds kind of boring, but from a science perspective, it's essential, get a better way of recording people's vaping behavior in their electronic medical records. And the reason for this is that that's where we got really good data on the harms of smoking. It was being routinely recorded and then people were being followed up. And we could say 30 years later, someone who smoked in the 1950s was much more likely to have lung cancer in the 1980s. We need that data and we particularly need to know it for people who don't smoke and just vape. So we can really get a better sense of what the harms might be from vaping.
Thank you very much for what you do and for taking time to be with us today.
Thank you so much.
Dr. Jamie Hartman-Boyce, Assistant Professor of Health Policy and Management at the University of Massachusetts. That's an Amherst Mass. And we want to hear from you. Have you tried to quit vaping? What methods did you try? What's been the hardest part for you? Tell us. Call us at 646-767-6532. That number again, 646-767-6532. Or send us a voice memo. Yeah, a voice memo. A file to sci fry at sciencefriday.com. Sci fry at sciencefriday.com.
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