The rising trend of vaping, why it is exploding, and what it means for public health

 

On season two of the Netflix drama House of Cards, when U.S. Vice President Frank Underwood gestured, electronic cigarette in hand, and uttered in his famous southern drawl, “It’s addiction without the consequences,” vaping society had already passed the point of no return.

Many assume the popularity of conventional cigarettes is maintained at least partly through smoking’s portrayal in the media; it is safe to assume, then, that vaping – the use of electronic coils as a heating mechanism for inhaling vapour which until recently may have been considered a passing fad – has thoroughly permeated the realm of niche culture and continues to work its way into the territory of normalization.

Views on this cultural trend are varied. There are those who swear by vaping as a way to stop smoking regular cigarettes. Others question its effectiveness, and decry the fact that there’s still so much we don’t know about the devices and their potential dangers.

Experts are still trying to paint a clear picture of various vaping products and their potential impacts on public health. In the meantime, there is no doubt that this trend is on the rise, which means that policymakers are under pressure to address e-smoking in an environment shrouded with uncertainty.

From smoke-ring blowing novelty users to lifetime researchers of smoking, U of T is home to people from all ends of the vaping scene. Right now, the possibilities span from the widespread resurgence of smoking addictions to the eradication of conventional cigarettes, and everything in between, leaving the future of these devices decidely murky.

Picking up vape

There are at least nine vape shops within walking distance of U of T. On my walk from Hart House and the closest one, EsmokerCanada at Yonge and Gloucester, I passed at least half a dozen people drawing on the curious and increasingly ubiquitous devices.

I went there to speak with Mario Martinasevic, the owner of the Canadian chain, to ask him about how he thinks the trend is evolving. When I arrived, I admit I was surprised to observe that the shop did not fit in with the ambiance of the surrounding downtown Yonge Street. EsmokerCanada is bright and spacious, with impressive glass displays lining the edge displaying hundreds of different products.

I found Martinasevic minding his shop, clutching an elaborate vape in hand. He invited me to sit and talk, occasionally dragging on an instrument which, to me, looks closer to a clarinet than a tobacco cigarette.

Martinasevic told me that he opened EsmokerCanada in 2011, and that the Yonge Street location is the one of the newest “brick and mortar” installations of the growing company.

“Our business has pretty much tenfolded since 2011,” Martinasevic says.

The clientele coming in are 70 per cent established smokers looking to quit, says Martinasevic, adding that he believes this is because the product has a higher success rate than other smoking cessation tools.

“This is due to not just giving you the nicotine fix but also giving you something to hold and actually gives you the physical satisfaction and also the psychological satisfaction,” he explains.

When a new client comes in looking to ease off of nicotine, Martinasevic will recommend they start with low vapour, high nicotine products and transition to ones that are lower in nicotine, substituting higher volumes of vapour.

The other 30 per cent of customers are reportedly hobbyists, or weekend users.

There are over 170 different products available at this shop, from simple, tubular systems with a battery, an atomizer, and a cartridge which resemble cigarettes (when I went, there was a sign out front offering these for free to new clients) to more sophisticated, systems with larger batteries and reservoirs for e-juice. Some of the products contain nicotine at varying strengths; others are just vapour fluids.

Kelvin Xu, a second year industrial engineering student, says he falls under the category of those using vape products to stop smoking cigarettes.

“[T]he smell, the taste and the health benefit… are why I prefer it over cigarettes,” said Xu.

While Xu said he picked up vaping on the advice of a friend, he doesn’t really see vaping as part of a cool trend.

“I would say there’s a slightly more edgier perception towards smoking cigarettes. Just because of movies and stuff,” Xu says, adding, “You kind of seem a bit cooler but also… it gives off sort of a bad feeling…So then vaping would be the not as cool alternative.”

At the same time, Xu is aware of a perception of vapers as a performative hobbyist group, as opposed to people who genuinely want to make healthier choices. “A lot of people rip on people who vape because of that,” he said.

One fairly recent user is Edmure,* a fifth-year U of T student who took up vaping about three weeks ago as a way to try to curb his reliance on cigarettes.

“This is not a sexy object. I always sort of took pride in being kind of like a cinematic smoker …I got a lot of compliments when I was younger,” Edmure said.

In contrast, Edmure described his use of e-smoking as a utility, not a performance.

“When I first bought it my roommate made fun of me a lot because I guess he had a better sense of there being a culture or at least an understood scene for vaping [of] a lot of guys with neckbeards on Youtube trying to see who can blow the biggest cloud,” he said.

“It was never really about that for me.”

Cessation, replacement, or new health hazard?

While Martinasevic attributes the growth of EsmokerCanada to the product’s usefulness as a cessation device, researchers in the field don’t agree about whether this is the case, or if cessation is even the right term to use when referring to smokers seeking out vape products.

“It’s quite split the field,” said Dr. Roberta Ferrence, Principal Investigator and Senior Scientific Advisor at the Ontario Tobacco Research Unit (OTRU), and professor at U of T’s Dalla Lana School of Public Health. “There’s a group even among scientists who feel …this may be a way out of the tobacco epidemic, or the cigarette epidemic, and there are others who feel that you need to look at the net impact,” Ferrence explained.

Ferrence works with Dr. Robert Schwartz, executive director of OTRU and principal investigator of RECIG, a Centre for Addiction and Mental Health (CAMH)-OTRU collaboration backed by provincial funding. The RECIG team is currently working on a widespread literature distillation and its own research, which will inform public policy decisions surrounding e-cigarettes in Ontario.

For Schwartz, the question of e-cigarettes as smoking cessation tools simply cannot be answered at this time due to a lack of scientific evidence.

“ …[W]e’ve just completed a systematic review of the literature that looks at studies of different sorts that have been done on whether people who are smokers of tobacco cigarettes successfully quit using e-cigarettes and whether we can attribute any increase in the likelihood of successfully quitting regular cigarettes to the use of e-cigarettes,” Schwartz explained. “And the answer is definitely no at this point.”

Schwartz went on to say that this doesn’t mean e-cigarettes might not still be useful for this purpose, but that the available evidence does not show that it is.

For Xu’s part, he feels that vaping has allowed him to reduce his dependence not just on cigarettes, but on the vape – and the nicotine it contains – itself.

“Personally…with cigarettes before it was a full on addiction. I ha[d] to smoke. Now that I have this vape pen on hand, and I don’t have to spend as much money to smoke it …I haven’t done it as frequently,” he explained.

If the evidence did arise in favour of e-smoking as a cessation tool however, Schwartz says this would entirely change the role that e-cigarettes play in society, especially in how they are sold.

In that event, he says “it should be brought in as a medicine probably and marketed in that way.”

Another member of the RECIG team and clinical director, addictions at CAMH, Dr. Peter Selby, says that cessation might not even be the right way to look at the role of vaping in public health.

“It would require [vaping] to become like a medicine which would then make it very difficult for it to then develop down that path,” Selby said of the devices as cessation tools.

“What might be a better way to think about it is… is it good replacement for cigarettes?”

Selby said that one way to look at vaping is as a technological advance.

“ …[C]igarettes are technologies that potentially came into being prior to the telephone, just a little after morse code. And we’re still using it. [I]t delivers 7000 chemicals, it still requires combustion, causes fires etc., and causes a lot of death and destruction, not so much from the nicotine in the device but from the non-nicotine constituents of cigarette smoke.”

He goes on to explain that vaping may be seen as a technological alternative to this outdated product, if it meets certain qualifications.

“ …[A]s long as this product becomes as safe as it possibly can and does not lead to harm by how it delivers the nicotine, and doesn’t lead to harm by propylene glycol – which is the other constituent [that] can lead to problems – then we might have a way safer product on the market that is more acceptable to smokers, and that creates the climate to ban cigarettes completely.”

And while the idea of banning cigarettes completely is enticing, there are many questions that follow Selby’s thought process of which he and his colleagues are acutely aware.

What are the health effects of vaping in and of itself? All other toxins aside, what problems arise from inhaling nicotine? Do e-cigarettes cause an addiction to nicotine the same way that tobacco cigarettes do? And, the “million dollar question” as Selby calls it, are e-cigarettes a gateway to using tobacco cigarettes, especially for youth?

What do we know? 

I asked Schwartz to shed some light on what we know about some of these questions. He tells me that, while there are some things we can say conclusively, e-smoking still occupies an enormous grey area in research.

“Well we know that [vaping is] not completely benign. We also can say with some degree of certainty that it’s less harmful than regular cigarettes.”

Knowing what we know about the impact of cigarettes, the space in between “not benign” and “less harmful than cigarettes” is huge. Meanwhile, Martinasevic reports that customers regularly come to his shop seeking a healthier lifestyle.

“ …[T]hey’re trying to get the nicotine out of their system, the tar out of their system, they’re trying to do more walking and what not, and more exercise…The nicotine is addicting but it doesn’t really kill us at the end of the day. It’s as addictive, as bad as caffeine, for instance,” Martinasevic says of his customers.

The perception, if not the evidence, indicates that e-smoking is an improvement to regular cigarette use. The effects of this trend, however, do not stop at the vaping devices themselves.

The evidence is inconclusive, according to Schwartz, as to whether vaping does lead to regular cigarette use, and notes that this is a concern among researchers.

Tobacco smoking rates are low among youth aged 12-18: six per cent according to Schwartz. This rate increases, however, to 23 per cent for the university-aged demographic. Meanwhile, the ever-use rates for vape are higher in both categories.

“There’s one good reasoned article from the states that track these people over time and they did find that a reasonable number then did pick up regular cigarettes after starting with e-cigarettes,” Schwartz said, adding that this one study is not sufficient to prove causation.

“Another concern is that people will start becoming regular e-cigarette users.”

Part of the reason this is a concern, according to Ferrence, is that there is a lot of misinformation about what e-cigarettes contain.

“You hear from people selling it that it’s just water vapour. That’s not true. There’s certainly propylene glycol which is a lung irritant. So you don’t really want to be inhaling that,” Ferrence said.

Schwartz also said that talking about e-smoking as a singular, cohesive practice is, in and of itself, a myth. Vape products, after all, vary enormously, and Schwartz pointed out that some flavourings in e-juices may contain additional toxins

To Ferrence, all of this is to say that we are dealing with a very risky product. “ …[A]s far as I know the only real potential value of e-cigarettes would be either to help people quit smoking or to be an alternative to smoking to people who might have smoked. But if they never would have smoked then it’s certainly not an advantage, “ she said.

A response in the face of uncertainty

In May 2015, the Ontario Legislature passed Bill 45, the “Making Healthier Choices Act,” which places restrictions on e-cigarette use akin to those placed on regular cigarettes.

Under the new law, which comes into effect January 2016, it will be illegal to sell e-cigarettes to minors under the age of 19 or to vape in indoor common spaces, and restrictions will be put on the products’ marketing and display. It is already illegal, according to Health Canada, to sell e-cigarettes and e-juices with nicotine, but, as Ferrence and Schwartz were quick to mention, this is seldom enforced.

For Schwartz, the precautionary principle – a public health term which refers to proceeding cautiously with trends whose impacts are not yet known – applies here.

“ …[I]deally the policy is evidence informed or evidence based. However, we have a situation now where the government is feeling pressure to do something about e-cigarettes when the evidence isn’t in yet.”

In Schwartz’ view, this precaution is a good idea.

Others are less sure. Dustyn Kennedy, an employee of EsmokerCanada, said that while some of the act’s measures – namelyage restrictions and indoor use – make sense, he is less convinced about steps to restrict marketing and display.

“That would probably help out tobacco companies if anything. Because our products are very unknown so there is a lot of learning, seeing, feeling, touching,” he explained.

Kennedy also said that it is presumptive to place these controls on the sale of e-cigarettes when there is still much to learn about the products’ health impacts. “If it’s that bad, why don’t we have testing to show that?” Kennedy mused.

And yet, as much as these measures are a precautionary response to vape products themselves, marketing is also undoubtedly on the radars of researchers.

Currently, Ferrence explained, companies are free to advertize e-smoking devices in Canada, something that is not the case for tobacco cigarettes.

“But, how can you tell from a photo?” Ferrence asked. “So you can have a big picture of a[n] [electronic] cigarette and it’s legal to put it up… even though we ban cigarette advertising in Canada, generally. So a big advantage to the industry is the opportunity to advertise again.”

The marketing climate of e-cigarettes is further complicated by the fact that there is more to market about them. High on this list is flavouring.

“ …[W]ho’s picking up bubble gum flavour? All these fruit flavours and ice cream like flavours?” asked Schwartz. Though he says he cannot be certain, he suspects the vaping industry is attempting to appeal to youth.

“ …[T]hat’s problematic if … the other half are saying it’s a great cessation device. Because they’re trying to lure people in with flavours who are not [yet] cigarette smokers,” Schwartz said.

In some cases, it is Big Tobacco doing the selling. In our conversation, Ferrence brought up the fact that she thinks all three major tobacco companies in the US have now acquired vaping companies as their subsidiaries.

She is right. Philip Morris (Altria corporation) has the rights to NuMark, a vape company using the tagline, “An Altria Innovation Company.” R.J Reynolds has the inventively named “R.J Reynolds Vapour,” which makes Vuse e-cigarette products. Lorillard bought blu eCigs in 2012, and was recently acquired by R.J. Reynolds in 2014.

Should this be a concern? As Ferrence pointed out, “Many times historically the tobacco industry have said, ‘we’re in the nicotine business.’ They never said ‘we’re in the cigarette business.”

Future outlook

So, what does the future of vaping have in store? It is a question that, Schwartz said, we would need a crystal ball to adequately answer at this point in time.

One benchmark to observe will be in January, when the Bill 45 legislation comes into effect. If the legislation is rigorously enforced, shops like EsmokerCanada will have to completely rearrange their store so as to comply with the rules prohibiting materials to be displayed.

Some of the advantages that e-smokers currently enjoy over tobacco smokers will also be taken away, including the ability to use their devices in indoor public spaces.

Schwartz also wonders whether the government will soon take a stand on the sale of e-products with nicotine. “[T]he government is going to have to make a decision at some point,” he said.

I am curious to see – if shops like EsmokerCanada are really growing due to the desire to quit smoking – whether their business will remain as robust if smokers do, in fact, quit.

Ann Kennedy, another EsmokerCanada employee, thinks a certain customer base will remain. “Some people just continue to do it. They don’t see nicotine as harmful compared to say alcohol or caffeine or things like that,” she says.

Another factor is what Ferrence calls co-use with marijuana, which, even if it is not as common as use with water pipes, happens.

“And if the government does decriminalize or legalize cannabis, then that is another whole factor in the market analysis of what’s going to happen with these.”

Given that the Liberals and the Greens are promising marijuana legalization in the present election campaign, and the NDP are calling for decriminalization of the drug, this kind of speculation is imminently relevant.

What remains are lots of big questions. How harmful is e-smoking? Does it act as a gateway to smoking tobacco cigarettes? Is it a better replacement for tobacco cigarettes? If so, is its uptake equivalent to the population that would otherwise have been smoking tobacco cigarettes?

These are important questions for which we do not yet have answers. While the OTRU tries to sort them out, people like Edmure,* and Xu remain optimistic that the trend is, at least for them, a step in the right direction.

Source : http://thevarsity.ca/2015/10/18/up-in-vapour/