Many times we conflate addiction with the use of illegal substances. In fact, the two substances that have the highest rates of addiction around the world are completely legal – and for some also lethal. We’re talking about alcohol and nicotine.
Globally the number of deaths due to smoking declined from 146 per 100,000 people in 1990 to 90 per 100,000 in 2017. Does the arrival of vaping threaten to undo this good news?
1. Wait, I need an overview. What is vaping, again? Vaping means using an electronic cigarette (or e-cigarette) to get your nicotine fix. Originally designed about 15 years ago to help people quit smoking, e-cigarettes have expanded to broader markets. Touted as a safe alternative to traditional cigarettes, almost 10% of adults in the United States said they “regularly or occasionally” vaped in 2018. Among young people, the rate is 20%. But vaping is not without consequences. Over 2,000 people have been diagnosed with severe lung disease and 39 people have died from e-cigarette-related respiratory illness. These lung injuries have become so common that doctors have created a new term for them: EVALI, or E-cigarette or VAping product use-association Lung Injury. There is no clear cause of EVALI, although some research suggests vitamin E acetate may be part of the story.
2. Vaping among adolescents. In 2016, the FDA banned the sale of e-cigarettes to minors, but vaping among teenagers has continued to increase. One study found that the rates of youth who say they vaped with nicotine in the past month more than doubled from 2017 to 2019: from 11 to 25% of high school seniors and from 3.5 to 9% of eighth-graders. Many blame youth-centered advertising from the e-cigarette company JUUL, which markets sweet flavors and an easily-hidden USB flash drive design. Unfortunately, this increase of vaping among youth has also translated to increase in cigarette use. In one study, recent vape users were more than four times more likely to report cigarette use at a one year follow up. Especially in youth, nicotine addiction from both vaping and cigarette smoking can lead to lack of focus, hyperactivity, and increased symptoms of depression and anxiety.
3. People with mental illness are more likely to smoke. People with mental illness consume 40% of all cigarettes sold annually in the United States. Individuals with mental health conditions are twice as likely to have tried e-cigarettes and three times as likely to use battery-powered nicotine-delivery devices. College students who have used e-cigarettes in the last year are more likely to have mental health histories and report low-self esteem. The relationship between mental ill health and smoking or vaping is complicated. Some individuals may smoke or vape in an effort to alleviate symptoms of anxiety or depression, but the utility of such efforts is unclear and the risk for addiction is high – putting people with mental disorders at elevated risk for EVALI and other nicotine-addiction consequences.
4. Making the case for vaping in some parts of the world. Whereas San Francisco recently became the first city in the US to ban e-cigarettes, some parts of the world are focused on the harm reduction benefits of vaping. In many places, vaping is promoted as a tool to reduce traditional smoking among people with mental health disorders. The Royal Australian and New Zealand College of Psychiatrists, for example, came out in favor of the use of vaping products for people with psychiatric illness based on the data indicating that e-cigarettes are a less harmful way to deliver nicotine to people who smoke. Compared to traditional smoking, vaping does appear to be the lesser of two evils. At the same time, I do worry about the ethics of settling lower standards in terms of health expectations and healthcare for individuals because they have mental illness. Such practices at least partially account for the well documented shorter life expectancy for such individuals. We can do better.
5. Overall science of vaping is still unclear. The data that we have thus far indicate that vaping is less harmful than smoking cigarettes. Vaping may have the potential to help some people quit smoking. Vaping is not associated with the same cancer risks associated with smoking combustible cigarettes. But vaping doesn’t eliminate nicotine addiction. And because it is perceived to be safe, vaping may actually be causing more people to become addicted to nicotine, especially young people. Vaping as a gateway to nicotine addiction and cigarette smoking for teens is not a good thing. On the other hand, vaping may be a positive harm reduction strategy for those who are already addicted to nicotine and want to quit smoking cigarettes.
We still have much to learn about vaping. We need more research to help provide greater clarity and inform recommendations. As we continue to collect precise data around who is vaping, whether they become addicted, and other health effects, we need to remember to pay particular attention to people with mental health conditions who have much at stake on this issue.