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Smoking has never been cool in my lifetime. But e-cigs are different, sort of.
"E-cigarettes are kind of a way of doing the same thing without getting the same harmful effects of the original cigarettes,” says 16-year-old Alexandra, a friend’s sister, who asked that her last name not be used.
Alex first tried "smoking" an e-cigarette, or "vaping," at a party. She said half of her friends vape, mostly when they hang out. But when it comes to smoking: "I only know like two people that actually smoke."
Her experience is familiar. I’m 20, and e-cigarettes are everywhere. Shuffling out of class, stumbling out of bars (I live in British Columbia where the drinking age is 19), or leaving a party, I see friends and classmates puffing e-cigarettes, large clouds of vapor swirling around them.
'Cool, Fun, Something New'
It’s hard to place my finger on exactly why friends think vaping is cool. It’s not cool the same way alcohol is seen as cool — universally so — but it's clearly cool in some circles. People will let you vape at parties and you don't get the same judgmental looks as you would with a cigarette.
A recent study in the Canadian Medical Association Journal claims the vibe of "cool/fun/something new” is what’s motivating kids to try e-cigarettes. Many of my friends crave new experiences and sensations; plus, who doesn't want to break the rules once in a while?
According to the CDC, in 2015, 16 percent of high school students reported using e-cigarettes in the last month. For comparison, teen cigarette use is the lowest it's been in 40 years, reports the CDC, with just 9 percent of high schoolers reporting smoking in the last 30 days.
The burning question for public health researchers is this: is all this e-cigarette use ultimately good for teens, because it keeps them away from nasty tobacco cigarettes? Or may it hurt them more than it helps them, because, as new research suggest, many kids who would never have smoked are willing to vape?
As one Boston-based researcher suggests, e-cigs help to "denormalize smoking," and may offer a public health boost.
It is unclear exactly what effects e-cigarettes have on health, especially when it comes to adolescents and long term impacts. Marketing campaigns that claim e-cigarettes produce nothing more than harmless water vapor aren't true — that much is clear. Toxins can be detected in e-cigarette vapor and there are concerning compounds in the flavoring of e-cigarettes.
Avrum Spira, a Boston University professor of medicine, is conducting research on the effects of e-cigarettes. His research has found evidence that cells (in a petri dish) exposed to e-cig vapor do experience effects similar to exposure to tobacco smoke.
Spira, in an interview with BU, said he can't say e-cigarettes cause cancer — the data doesn’t support that — but there are definite causes for concern.
In addition, for younger users, it’s thought that nicotine, which is present in most e-cigarettes, may interfere with brain development.
Results generally conclude that while e-cigarettes aren't helping anyone's health, they are safer than cigarettes. But that greater safety is less comforting if they pull large new cohorts into cigarette use, as some early research now suggests.
Jessica Barrington-Trimis is a postdoctoral research associate at the University of Southern California who has been researching teenagers and e-cigarettes for the past two years. She has published a series of papers that look at why teenagers use e-cigarettes and how many teens are using them. She also is looking to see if e-cigarette usage contributes to cigarette usage. Barrington-Trimis calls the results “dire."
Barrington-Trimis and her colleagues found that more than 40 percent of 11th and 12th grade students who used e-cigarettes had never smoked a combustible cigarette. This evidence further supports the idea that e-cigarettes are "recruiting" kids who would have never smoked to vape.
“That was one of the first indications that e-cigarettes may be recruiting youth who otherwise would not have ever had smoked cigarettes to e-cigarettes,” explained Barrington-Trimis.
Then, with the help of Dr. Adam Leventhal, a psychologist and associate professor of preventive medicine and psychology at USC, Barrington-Trimis published an article looking at risk profiles of teens who used cigarettes and e-cigarettes, as well as dual users. Their findings again suggest that e-cigarettes may be "recruiting" youth who would have never tried combustible cigarettes to try e-cigarettes.
In May, Barrington-Trimis published another article, this time finding that teens who were using e-cigarettes were more than six times as likely to start smoking as kids who had never vaped.
The team’s most recent paper, just published in Pediatrics looked at rates of cigarette and e-cigarette use in high schoolers from multiple graduating classes between 1995 to 2014. As expected, cigarette usage declined, but only until 2014. In the class of 2014, the first class that had access to e-cigarettes, the combined rate of cigarette and e-cigarette usage was higher than the rate of cigarette usage in 2004 and 2001.
In other words, it seems, teens aren't just substituting e-cigarettes for cigarettes as many experts were suggesting; e-cigarettes were recruiting kids who wouldn’t have otherwise tried cigarettes to vape. It is still unclear whether e-cigarettes lead to combustible cigarette use though. That switch is exactly what public health officials don't want to see happen.
“These pictures paint a bit of a dire picture about the state of adolescence tobacco control right now,” said Barrington-Trimis. "Future investigation into what is actually happening is needed."
But might this increase in teen vaping not be so dire? It all comes down to harm reduction, an idea that health officials have been applying for years, from sex education — teaching safer sex instead of abstinence — to creating needle exchanges for heroin addicts.
Put another way: If you're on a sinking ship, you get on the lifeboat. You don't ask: 'Are these lifeboats safe' or 'what do we do once we're on them?' You save as many people as possible before the ship sank. That’s harm reduction in a nutshell.
“People are going to do behaviors that are not necessarily good for them. Let’s at least minimize the risk. That is going to save so many lives,” said Dr. Michael Siegel, a professor of community health sciences at Boston University. “If we had a preference, we wouldn’t want young people to smoke or vape. The problem is we don’t live in an ideal world and the reality is that young people are going to try and find some method of exercising their independence and freedom, their rejection of autonomy and their rebelliousness. The question is really what form that is going to take, not whether it’s going to happen,” said Siegel.
E-cigarettes could have huge health benefits as cigarette substitutes in adults and long term smokers, Siegel argues. But they could also be useful in harm reduction in teens.
“If anything, I think vaping is displacing smoking as being the new cool thing to do. You can say well, that’s a bad thing, but I’m not sure it’s bad. Ultimately it could be a good thing. It’s helping to denormalize smoking,” Siegel explained. "If teen smoking is going down drastically, I think that’s a good thing and it’s going to improve the public's health even if it comes at the expense of seeing an increase in e-cigarette experimentation.”
Not everyone in the public health community agrees with Siegel. The CDC warns against dual use on their website, claiming “[Dual use] is not an effective way to safeguard your health, whether you’re using electronic cigarettes (e-cigarettes), smokeless tobacco, or other tobacco products in addition to regular cigarettes. Quitting smoking completely is very important to protect your health.”
The American Lung Association “remains concerned about their [e-cigarettes] impact on the public health,” citing that they are the the most commonly used tobacco product (even though they contain no tobacco) by youth.
A lot more research needs to be done before the effects of e-cigarettes, especially long-term effects, are understood.
But there's already reason to be wary of limiting sales of e-cigarettes just like cigarettes.
For instance, some states are raising the minimum tobacco use age from 18 to 21 in response to the rise of e-cigarettes. But studies from Yale and Cornell show that when the age is raised, teen use of combustible cigarettes increases.
Of course, it may be scary when you see data that says more and more kids are using e-cigarettes. But we don't yet have the whole story on whether that means net harm or net health benefit. And maybe my generation's public health officials will have learned so much from the previous generation's campaign agains cigarettes that they'll bring in smarter regulations and PR campaigns.
Personally, I’ve never tried vaping (or smoking) and, after learning more, I don’t think I ever will. Frankly, I used to judge vapers pretty harshly. Now, I see them in a slightly different light — at least, until more data rolls in.
Editor’s Note: this post has been shortened from its original version.