Vaping: A valuable harm reduction tool or a public health concern? Experts weigh in

From our own research and understanding of the chemistry that can occur with the chemicals in vapes, it really is a public health concern.

We’re in an unusual situation where obviously the phenomenon of vaping has taken hold – and it’s not just among older tobacco smokers. It is clearly in every school in Ireland and North America, and you see it gaining popularity in young adults. But what’s going to happen to these young vapers 15 years from now? Much like tobacco, if you vape today as a teenager, you may not see the physical health consequences for another decade or two.

You don’t have to be a scientist to know that if you inhale a lot of different chemicals into your lungs, the health outcomes won’t be good.  But the counter argument from the industry says that we’re trying to save the people who are already addicted to tobacco smoking.

Yet it seems like we’re having a similar argument to the one that happened 30 to 40 years ago with tobacco smoking: At the time, scientists were showing evidence that, yes, there are severe health impacts from tobacco smoking but there was a very significant industry lobby saying the opposite. From my point of view, for vaping, I think it’s obvious that there will be negative health impacts coming down the line. These impacts may not be identical to tobacco as there is a new untested cocktail of chemicals involved in vaping.

We may also encounter the occasional catastrophic event like in the EVALI outbreak in the United States, which was attributed to just one single chemical, vitamin E acetate, which we showed in the published literature breaks down due to vape heating causing a very toxic gas (ketene) to be produced.

“We can expect a slow accumulation of damage over years of exposure.”

In general, what could be expected in nicotine vaping will more likely be a slow accumulation of damage over years of exposure. There is an under-appreciation, especially in the younger generations, as to how addictive vapes are. They’re set up and designed to be addictive. There is always a perception when you’re younger that you can quit whenever you want. But that may actually not be so straightforward as nicotine is very addictive and it’s not an easy addiction to overcome.

What is urgently needed is the removal of flavoured vapes from the market. These flavours are not necessary to deliver nicotine to somebody who is addicted to tobacco smoking, and they are the main attraction and future health risk for the never-smoked younger generation.

In Ireland, our government does not advise vaping as a means to quit tobacco smoking. This is in part due to the research literature showing that addicted tobacco smokers can end up as dual users, which is the absolute worst of both worlds because now you’re getting exposed to all the chemicals from smoking and a different set from vaping. Several studies have shown that vaping is not better for quitting tobacco smoking than clinically approved methods and this [vaping] claim appears to be just an industry marketing ploy.

These unproven vaping attempts to remedy nicotine addictions of older tobacco smokers risks transferal of new health issues to younger generations. A protective balance needs to be struck for both cohorts rather than pitching one against the other. If protections are not put in place for the younger never-smoked generations, it is unlikely they will thank us in the future for allowing a new addictive health scourge to take hold.

Vaping is absolutely about harm reduction.

Nothing is risk free. But what I do know is that public health organizations around the world have found that vaping is at least 95 per cent less harmful than smoking. I also know that not one Canadian died last year from vaping. Almost 48,000 Canadians died from smoking. Full stop.

Harm reduction is a compassionate and pragmatic approach. It acknowledges the reality that people will continue to use substances, regardless of laws or policies. Instead of punishing individuals for their choices, harm reduction focuses on minimizing the risks and harms associated with substance use. It offers support and practical strategies to improve health outcomes.

Vaping offers an incredibly significant reduction in risk. Imagine the lives that could be saved and the suffering that could be prevented if more people switched from smoking to vaping.

Vaping offers an incredibly significant reduction in risk.

Canada has set a goal to reduce smoking rates to under 5 per cent by 2035. This is an ambitious and achievable target, but only if we embrace harm reduction strategies like vaping. Already, youth smoking rates have dropped to below 5 per cent, showing that progress is possible.

When we look at countries like Sweden and New Zealand that have embraced tobacco harm reduction in their public health policies, we see some amazing results. Sweden is virtually smoke free, and New Zealand is well on its way. It can be done. The Canadian government simply has to be courageous and embrace harm reduction.

The most recent Cochrane review on electronic cigarettes concluded that e-cigarettes increase quit rates among smokers. This means that vaping is not just a safer alternative; it is also an effective tool to help people quit smoking altogether.

Based on the definition of harm reduction and common sense, vaping is and should be embraced by all. The question in Canada we should be asking is why the Cancer Society, the Heart and Stroke and other non-government organizations are vigorously opposing vaping as a harm reduction tool.

In their initial phase, e-cigarettes were supposed to assist people who smoke and are unable to quit. What has happened in Canada is that there has been tremendous onset by youth and young adults who otherwise would never have smoked, and who have become addicted to nicotine. We now have 730,000 Canadians who vape and who have never smoked.

E-cigarettes are here to stay. Health Canada states that e-cigarettes are less harmful than conventional cigarettes if the person quits smoking completely and there’s no dual use. A problem is that there is a very significant number of people who vape and are also continuing to smoke, so you’re not having the intended health effect.

Moreover, dual use helps some people to keep smoking, for example by vaping in some places where you can’t smoke, such as the basement at home. Things like this and the low cost of e-cigarettes are motivating dual use.

E-cigarettes have become less expensive in recent years. Companies have created disposable e-cigarettes that last 10,000 puffs where many early products just two years ago were only 500 puffs. In terms of cost, this means that it used to cost 2.2 cents per puff; now we’re looking at 0.3 cents per puff. The cost has really come down and youth use of these disposable products has soared in the last few years in Canada, the U.S. and the U.K.

The cost has really come down and the use of these disposable products among youth has soared in the last few years.

In Canada, on a population health basis, vaping products have not been shown to reduce smoking prevalence overall. While smoking has continued to decline in Canada, the reason has been tobacco tax increases, massive cigarette industry price increases and a series of other measures.

E-cigarettes will remain available but need to be properly and better regulated. We have this enormous problem of use among youth and people who have never smoked, and we need serious measures in response. For example, increasing taxes, raising the minimum age of sale to 21 as the U.S. has already done, and limiting sales to specialty stores only as we have done with cannabis.

Flavours are a major reason why youth begin to vape. We need to ban e-cigarette flavours other than tobacco flavour and we’re urging the federal government to finalize the June 2021 draft regulation as soon as possible. We have six provinces and territories in Canada that have banned flavours other than tobacco, five states in the U.S. plus the District of Columbia and a growing number of European countries.

The intended use for e-cigarettes has not worked out in Canada on a population basis. That’s a tremendous concern. The 730,000 Canadians who vape and who have never smoked is projected to increase substantially year after year through onset by youth and young adults. In the long term, that’s going to be a significant public health problem for Canada unless there’s successful regulatory action.

Vaping is both harm reduction and a growing health concern. The evidence now shows that nicotine e-cigarettes are as effective, if not more effective, than other forms of smoking cessation pharmacotherapy. It’s become clear that there is a role for this device as a smoking cessation tool. We should be aware of when and how it’s recommended. Obviously it’s much less well-studied than other smoking cessation aids, so we always have some hesitation in medicine about anything that’s newer.

But the other big caveat is that many of these trials don’t tell us what proportion of patients are still using the nicotine delivery system at study end. The studies that do indicate that in some cases, patients have merely swapped one addiction for another, which is very different from what we see with traditional nicotine replacement therapy (NRT) or varenicline, a very effective medication used for smoking cessation. This is a concern because we still do not know the long-term effects of vaping.

Because of this caveat, clinical recommendations for vaping as a smoking cessation tool will probably be limited to cases where all other options, like NRT’s or varenicline, have failed, at least for now.

If you’re swapping one addiction for another, we’ll only really know if it’s better than smoking in the long term, in another 15 years.

So then why is this also a public health concern? Because we do not limit its use to people who are trying to quit smoking. Is it harm reduction for the smokers? Maybe. But we still don’t know what the long-term risks are, so if you’re swapping one addiction for another, we’ll only really know if it’s better than smoking in the long term, in another 15 years.

In the end, we don’t want people who currently are not smoking to start doing this. For those of us who see patients who are smoking and struggling to quit and have failed everything else, this may well represent a lower risk alternative. But we don’t know that for sure and that’s where a lot of us clinicians struggle. That’s why it’s important to maintain nuance and perspective here, especially as the literature is evolving.

In terms of regulation, I’m worried we may have missed the boat a bit. It’s almost impossible to regulate a drug once it’s out there. But I do think that what is already happening is the minimum starting point – controlling sales to minors, controlling advertising and restricting flavours that are clearly targeting minors.

And there should at least be more regulation on the manufacturing side to ensure that we’re not contending with incorrect labelling, nicotine content errors, dangerous contaminants in vape cartridges and exploding devices.

The single most important thing to know is that young people are not smoking anymore. If you look at the statistics, Health Canada says it can no longer accurately count the number of people who smoke in the younger age groups. It can’t find enough smokers to produce a statistically valid number.

It is lower than it has ever been, and it is lower than it was predicted that it would be. This is similar in the UK and the United States. Young people have pretty much stopped smoking.

The goal of under 5 per cent prevalence of smoking has been achieved in the younger age group. We know that if people don’t start smoking when they’re young, they’re not going to start smoking when they’re 20, 30 or 40. So, this is the beginning of the end for the tobacco industry.

The explanation is simple and obvious: Some young people are not smoking because they’re vaping instead – and that should be really, really good news. Anybody who looks at it even vaguely objectively has to recognize that vaping is many, many times safer than smoking cigarettes, whether it’s five times, 20 times, or 100 times – it is still vastly safer.

Young people in particular switching from smoking to vaping is a huge triumph. It’s happening not because of Health Canada or the Canadian Cancer Society, it’s because people are just being rational consumers and switching to a safer product.

Young people in particular switching from smoking to vaping is a huge triumph.

It’s true when we say we don’t know the long-term risks of vaping, but that isn’t the way all of medicine works. We never know the long-term risks of anything. As soon as we introduce a new operation, a new medication, a new vaccine, we know a certain amount about it. We know what it does in the short term, and we know historically, based on what’s in it, how people have responded to similar substances in the past and how they are likely to respond in the long term.

The same can be said for vaping. We know exactly what’s in a vape. We know from comparative studies what similar chemicals have done to people in other situations, so we can predict that vaping isn’t going to kill a bunch of people. There is no evidence that vaping has really killed anyone. No vapers, for example, have ever died of popcorn lung. There’s been a big fuss about that from the American Lung Association, but it’s completely untrue.

The EVALI outbreak was caused by contaminated THC products. The lesson we should learn there is that all these products need to be made by reputable manufacturers that have gone through government approval processes.

And yet with these new taxes, all we’re doing is encouraging people to buy crap off the back of a truck because it’s going to be cheaper than what they can buy legitimately.

People are complaining about young people buying and using vapes. There’s a couple of issues there. One is that if we’re talking about people aged 20 to 25 – about 10 per cent of them use vapes – these are adults, and they can do what they like. Drinking alcohol and smoking cannabis are much more dangerous than vaping.

If you look at the younger people, people under 18 or 19, it’s illegal to provide minors with vape. That’s the law. If they’re vaping, we’re just not enforcing that law. But then we create other laws banning flavours and adding taxes. But why are we bothering to create these new laws when we should just be enforcing the old laws? It doesn’t make sense.

It may be difficult to weigh these opposing views, but I come down on the “health concern” side of things. This is in part because as a pediatric respirologist, I see the impact of vaping on the younger population. But also, I look at the overall net impact of vaping.

There are certainly proponents of vaping that argue it is “safer” than smoking. However, we do not live in a world where you have to choose between vaping or smoking.  Neither is the preferred option

Neither is the preferred option.

The idea that you have to choose is false and plays into the hands of those who will benefit financially from vaping. Moreover, we are still not completely aware of all the harms of vaping and so while it is hard to imagine anything worse than smoking, that is not to say that vaping is safe.

I see the disproportionate impact on young people.  The majority of those who vape are teens and young adults. They are signing up for a lifetime of nicotine addiction and the accompanying toxins associated with vaping – and for this young population, there is no real benefit.