As an outbreak of severe lung disease and deaths among users of electronic cigarettes continues to spread to new patients and states, many may be wondering if the products are safe, especially smokers who may use e-cigarettes to get off tobacco. Andrew Hyland, chair of the Department of Health Behavior at Roswell Park Comprehensive Cancer Center, says "yes, but...."
"The authorities are taking this very seriously. They're basically treating this as an outbreak, a disease outbreak," said Hyland, who runs the New York State Smokers' Quitline, the tobacco program based at Roswell Park that helps some 40,000 people a year. "This is not ebola, but that's the seriousness that they're working to try to investigate what's going on."
Hyland called it a "fast-emerging story" and changing every day - and there is so much more to learn about these relatively new vaping products, especially as they evolve.
"Some of the early products looked like cigarettes and, in reality, they didn't really deliver much nicotine," he said, "but more recent products - tanks and mods, things that the user can adjust the voltage and put in their own e-liquid - have different characteristics."
Products like Juul are the next evolution, Hyland said. They deliver nicotine much more effectively than older products. One of the reasons it does this is salt-based technology.
"Juul figured out the chemistry, so that the nicotine at a higher level and more rapidly, which makes them more appealing, frankly. I would put the addictiveness of Juul comparable to what we would see in a tobacco cigarette."
However, there remains no agreement on how harmful vaping products can be to users.
Public health officials are reporting hundreds of previously healthy people across the United States being hospitalized with pneumonia-like symptoms linked to vaping. At least a dozen cases have been fatal.
"What it appears to be is that most of these cases related to vaping tainted THC oil, tainted marijuana. It's not been identified in every single case, but that does seem to be a common element in many of them," Hyland said. "It's generally regarded as being safe, but when you burn it or aerolisize it and put it in your lungs, when you put an oil into your lungs, that can have some complications."
Hyland said these are mostly "home-brewed" vaping products. He said these symptoms have not been reported with medical marijuana THC.
A lot of the discussion has been focused on children, because the nicotine in vaping products - and in tobacco cigarettes, for that matter - has been shown to be addictive and harmful, particularly on a person's cardiovascular system. Hyland said nicotine also affects how the brain grows "up until the early- to mid-20s," and there has been enormous growth in vaping among youth.
"The most recent data, just from a week or two ago, 2019 data, 27.5% of high school students report vaping," Hyland said. "That's up one-third from the previous year. In 2018, that was up two-thirds from the year before. So a more than doubling in just a two-year period. Very dramatic."
This has occurred, he said, while cigarette smoking has gone down among youth and the total number of children using any nicotine product has remained constant. And kids who vape are more likely to smoke later in life; most cigarette smokers started when they were young, Hyland said.
So where do we go from here?
Hyland said the variety of products available to smoke and vape - including tobacco and e-cigarettes, cigars, smokeless tobacco, hookah, water pipe - are "addictive, deadly" products and the #1 preventable cause of death in the country; they are "an added risk" to anyone who does not already smoke or vape.
"My recommendation, and what we know, is that a comprehensive approach is what works best," he said. "So at the most basic level, if these harmful products can be made less affordable, less accessible to kids, less appealing and less addictive, but the most dangerous products should get an extra measure. What are the strategies to do that?"
That could include higher taxes on purchases, like the e-cigarette tax expected to pass soon in New York; raising the age limit for purchases and banning flavors, as Gov. Andrew Cuomo has signed on e-cigarettes; and restricting e-cigarette advertising, as major broadcasters are now refusing to accept.
And he still recommends vaping as a tool to quit smoking. There needs to be more research, but Hyland said he has heard many stories from those who come for help at the Smokers' Quitline that vaping was the only method that helped them quit tobacco.
"To put it into context, every four minutes someone dies from lung cancer in the United States caused by cigarette smoking, so whatever you have to do to get off the cigarettes is going to yield the biggest health gain for the user," Hyland said. "The long-term health risks from vaping are still not clear, but I think it's almost certainly less risky than cigarette smoking because there's just fewer toxins that are in there."
Hyland noted that it took decades to understand the long-term risks of cigarette smoking.
"The events and the attention that's been placed on this has been a real wake-up call to people," he said. "You know, we've got this problem and it's been going on right under our nose, but enough is enough and it's time to act in a comprehensive way."