'You should absolutely be worried about vaping'

There has been a stream of alarming news reports about vaping. Public health officials say it may have caused a mysterious lung illness that killed a man in Illinois. In Texas, doctors say vaping blocked a teenage boy’s lungs. And almost 150 people across the country have been hospitalized after vaping marijuana or nicotine.

But wait — electronic cigarettes are good in some ways, aren’t they? What about those ads showing how they’ve helped people quit smoking regular cigarettes?

In this Q&A, a pair of experts at the Medical University of South Carolina who come at e-cigarettes from different perspectives weigh in.

Morgan Khawaja is a pediatrician with teenage patients who use e-cigarettes and have chronic coughs and asthma flare-ups. She’s also an assistant professor in the College of Medicine.

Matthew Carpenter is co-leader of the Tobacco Control Program at MUSC Hollings Cancer Center. He holds a doctorate in clinical psychology and is a professor in the College of Medicine. He speaks to parent groups about e-cigarettes.

Q: How big a deal are e-cigarettes? Should I really be worried if I’m a parent, or is there too much hype?

Khawaja: Yes, you should absolutely be worried. The use of e-cigarettes has been steadily increasing since they came out on the market. Previously, there was a downtrend in tobacco use among youth, but with the increasing popularity of e-cigarettes, nicotine use in adolescents and young adults has risen. One study in 2018 revealed that 1 in 5 high school students and 1 in 20 middle school students use e-cigarettes.

 

 Part of the reason for this is the marketing that e-cigarette companies can use. They can advertise in various ways that traditional cigarette companies are not allowed to. In the past, specific marketing tactics have been deemed illegal for traditional cigarette companies to use because they’ve been shown to increase the rate of youth initiation and the eventual progression to long-term tobacco use. We need the government to institute the same laws and regulations for e-cigarettes that we have for traditional cigarettes.

Carpenter: Parents and educators should be concerned about youth uptake of e-cigarettes. This is not hype. E-cigarette usage among kids is increasing, leading to nicotine addiction and the potential for progression to traditional cigarette smoking.

But we also need to remember that e-cigarettes are not nearly as harmful as combustible cigarettes. We absolutely agree that we need regulations on e-cigarettes, but we need even tighter, not the same, regulations on combustible cigarettes.

Q: The news reports about people with illnesses possibly linked to vaping are scary. Is that something you’re seeing in our area?

Khawaja: In my outpatient practice, I’ve seen asthma exacerbations and chronic coughs in teens who smoke e-cigarettes. I cannot comment on whether it is directly linked to vaping, but we know that inhalants and smoke of various kinds are triggers for these problems in children and in adults.

Q: So what’s in e-cigarettes that’s problematic?

Carpenter: Newer e-cigarettes, particularly JUUL, have very high levels of nicotine, which means they can be addictive. The salt-based formulation of nicotine in JUUL means that use is less aversive.  For first time users, having a less aversive experience — as compared to combustible smoking — increases the chances of continued use.

Khawaja: They also contain flavoring chemicals and many other additives. As of right now, these ingredients are not federally regulated, so any e-cigarette solution may contain various amounts of different chemicals. They are not required to list all ingredients or amounts of ingredients on the packaging, so you have no idea what you are being exposed to.

Q: You mentioned flavoring. There’s more and more of it out there, with descriptions like strawberry milk and peach madness. This has to be aimed at young people, right? Should something be done about this, and if so, what?

Carpenter: Flavors entice youth uptake. There is no reason for the myriad flavors. The FDA is moving towards restricting flavors, which is great. But this will be a long process that is likely to be litigated for years.

Khawaja: I have had multiple patients tell me, “Yes, I vape, but I use the flavored solutions, so it’s not as bad.” In 2009, the Family Smoking Prevention and Tobacco Control Act banned flavoring from conventional cigarettes because it encouraged youth initiation of tobacco use and addiction. This rule should be expanded to include e-cigarettes.

Q: How can I tell if a child is vaping?

Carpenter: Parents and educators should have continual dialogue with kids, including middle schoolers and high schoolers, about vaping.  This is not a one-time “talk with your kids,” but an ongoing conversation.

 

Khawaja: Create an environment in your family in which you can talk to your kids about substance use of any kind. When asking about tobacco products, ask them specifically about vaping, Juuling, e-cigarettes, etc. So many times, I ask patients in my clinic if they use tobacco products and their answer is no. I then ask if they vape or use Juuls and the answer often changes to yes. There is a disconnect between what vaping truly is.

Make sure they know that even if they use flavored solutions, they all contain nicotine and nicotine is very addictive. Talk to them about the long-term effects of tobacco and nicotine. Even though we do not know the long-term effects of e-cigs yet, we can extrapolate from what we know of traditional cigarettes.

Q: But aren’t e-cigarettes good in some cases? The current ads for Juul emphasize its use as a way for adult smokers to quit smoking traditional cigarettes.

Carpenter: Combustible smoking is far more harmful than e-cigarettes. Cigarette smoking kills half of all users. We can never lose sight of that. I would never say that vaping is better for you than cigarettes, but I would say that vaping is less harmful for you than cigarettes. 

Most evidence suggests that e-cigarettes can help adult smokers quit, largely because they are a better, more efficient delivery of nicotine compared to patches, gums, etc. So the things that make e-cigarettes addictive are the same things that make them more effective substitutes for smoking.

If regulated appropriately, we can figure out how to keep e-cigarettes out of the hands of people who shouldn’t use them, kids, and accessible to those who might benefit from them. 

Khawaja: Neither e-cigarettes nor regular cigarettes are good or acceptable for youth. Period.

Q: Where do you see the e-cigarette trend going from here?

Khawaja: Unfortunately, it seems that e-cigarettes are becoming more and more popular. Kids are vaping during school even. Something must be done to decrease this popularity.

Carpenter: E-cigarettes are not going away. Adolescent uptake is a huge concern, and we should support public health efforts to reduce nicotine initiation among youth. The FDA has a nice public service campaign, targeted at kids directly, called the Real Cost. It seems good, but it will take time before we can tell if it is having any effect.