There’s currently a mysterious vaping-related illness causing life-threatening lung injuries and death—maybe you’ve heard? In fact, as of this week, the CDC counts more than 1,000 cases of vaping-related lung injury across 48 states, as well as 18 deaths. Even scarier is the fact that these issues are primarily affecting young people; 80% of those affected are under 35, and about 20% are between the ages of 18 and 21.
But we’re still waiting on answers about what exactly is causing the issue. And in the meantime, the recommendations from health officials have been confusing—particularly for people who use e-cigarettes to cut down on traditional cigarettes. If you’re not totally sure how you should be responding to this public health crisis, you’re not alone.
Wait, remind me, what’s going on here?
We still don’t really know. On one hand, evidence from test results is mounting that illegal cannabis- and THC-containing vapes are the issue. A recent editorial published in the New England Journal of Medicine concluded that the vast majority—but not all—of those affected by the vaping-related illness report using cannabis- or THC-containing vapes.
And in a report released last week, test results from California-based cannabis testing lab CannaSafe confirmed the presence of both vitamin E acetate and pesticides (both of which can become dangerous when heated and inhaled) in the majority of illegal vapes they tested—but not in any legal cannabis vapes, suggesting there is scary stuff out there in an unregulated cannabis market. However, a new study, also published in the NEJM, found that the lung injuries in 17 patients look more like chemical burns rather than the result of inflammation due to inhaling fats in vape liquid.
At the same time, big companies and government officials have been quick to lay down the law on legal nicotine e-cigarettes. Walmart removed e-cigarettes from its shelves. Health officials in Michigan and New York voted to ban flavored e-cigarettes. (The ban in New York was later blocked in court.)
Proponents say actions like these have been a long time coming, especially because they’ll help keep younger people—particularly those who have not been exposed to nicotine before—from getting their hands on flavored nicotine vapes we don’t know that much about. But critics tell us this won’t get to the root of the vaping-related illness and, in reality, will only make it harder for adults who do find legal e-cigarettes to be helpful to actually access them.
So what is a responsible e-cigarette-using adult supposed to be doing here? Should you give up vaping entirely? What can you do if completely quitting nicotine simply isn’t feasible for you right now? What exactly do we know about the health risks of vaping versus smoking? We spoke to a few pulmonologists and addiction experts to find the answers to those questions, and although they do disagree on a few things, in general there is some consensus about how to keep yourself as safe as possible.
No, you should not go back to smoking traditional cigarettes.
Before we go any further, we really gotta review the known deadly risks associated with traditional combustible cigarettes: Smoking causes about 480,000 deaths in the U.S. every year, according to the CDC, which amounts to nearly one in five deaths. Smoking strongly raises your risk for many serious diseases, including lung cancer, chronic obstructive pulmonary disease (COPD), stroke, and heart disease.
“We know there is a very strong connection between cigarette smoking and COPD, heart disease, strokes, and different kinds of cancer, especially lung cancer,” Humberto Choi, M.D., a pulmonologist and critical care specialist at Cleveland Clinic, tells SELF.
Because these risks are very well established, “we can very strenuously argue there are clear health benefits from quitting smoking combustible cigarettes,” Enid Rose Neptune, M.D., pulmonologist and associate professor of medicine at Johns Hopkins University School of Medicine, tells SELF.
Whatever you decide to do, going back to traditional cigarettes is not the answer.
Everyone agrees that the best course of action, if you can, is to quit vaping.
The CDC’s recommendation for anyone who vapes right now is to stop vaping entirely, including avoiding e-cigarettes and THC-containing products. And, really, the only way to completely eliminate harm from nicotine—or any drug—is to “never use the product or stop using it; in other words, to have zero exposure,” David Abrams, Ph.D., professor of social and behavioral sciences at the NYU College of Global and Public Health and codirector of the Tobacco Research Lab, tells SELF.
On top of the possible vaping-related lung illnesses, there are other risks associated with vaping nicotine. It’s not a completely harmless act—even without the combustion factor. “We know that lifelong nicotine addiction is problematic,” Dr. Neptune says. It can cause withdrawal symptoms, including mood changes and difficulty concentrating, Dr. Choi says.
Those risks are not as deadly as the risks that come with traditional cigarettes. But the fact is that we don’t have all the data on e-cigarettes, which means there could be other risks that haven’t been discovered yet. For instance, we don’t know whether e-cigarettes have the same links to serious disease that traditional cigarettes do, Dr. Choi says.
“Unfortunately, we don’t know much about the long-term risks of using vaping products,” Dr. Neptune adds. “Much of the information that we have about combustible cigarettes—meaning the risk of cancer, the risk of chronic lung disease and cardiovascular disease—all of that may very well be attached to vaping, but we currently don’t have the data.”
There is also some evidence that vaping nicotine can increase your risk for cardiovascular issues (albeit nowhere near as much as traditional cigarettes), Dr. Choi points out. And, as SELF explained previously, we really don’t know much about the effects of vaping flavorings on the lungs.
Ultimately, the best option is to quit vaping completely.
If you’re using e-cigarettes to quit smoking, you should know that it’s not really designed or regulated for that.
Even if you’re using an e-cigarette to help you quit smoking traditional cigarettes—or you’ve already completely transitioned to the e-cigarettes—experts say it’s worth thinking about transitioning away from the e-cigarette completely.
“The reality is the conventional tools that we have for smoking cessation are very effective if used in the way they’re intended,” Dr. Neptune says. Those tools include nicotine replacement therapies like gums, patches, and lozenges, which are FDA-approved for smoking-cessation purposes and designed to be used for a few weeks at a time. Sometimes doctors also recommend using medications like bupropion (Wellbutrin) and varenicline (Chantix) to help smokers quit.
“We don’t advise using e-cigarettes to quit smoking,” Dr. Choi says, because we have these protocols already that have been through the FDA-approval process for that exact use. E-cigarettes have not been through that process, so most doctors advise patients to stick with the nicotine replacement therapies and medications that we already know can help.
Unfortunately, those methods don’t work for everyone. “If the e-cigarette has worked to keep them off cigarettes, my guess is almost all of them have already tried desperately everything else, including nicotine-replacement therapy,” Abrams says. “So I’m skeptical that suddenly they would be able to then use [nicotine replacement therapy] when it’s failed previously.”
Theoretically, e-cigarettes should have some advantages over traditional nicotine-replacement therapies, Thomas H. Brandon, Ph.D., director of the Tobacco Research & Intervention Program at Moffitt Cancer Center, tells SELF. Compared with things like the gum and the patch, e-cigarettes deliver nicotine more efficiently and in a way that’s more similar to smoking, including the hand motions and inhalation/exhalation, he says. “These are some things that smokers find comforting and reinforcing,” says Brandon, who is also on the advisory board of Hava Health International, a company trying to get an e-cigarette FDA-approved for smoking cessation.
Because e-cigarettes are not FDA-approved for smoking cessation, we’re lacking clinical trials that would conclusively prove that e-cigarettes are useful for that purpose, Brandon says, which would make him and others a lot more confident in this recommendation.
Here’s what the research says about using e-cigarettes to quit smoking.
Recent large-scale studies about vaping as a form of nicotine replacement therapy are somewhat encouraging but also flawed.
One of those studies, published in 2013 in PLOS One, was a yearlong randomized controlled trial involving 300 smokers who weren’t interested in quitting. The participants were broken up into groups of 100 people. The first group got e-cigarettes with 7.2 milligrams of nicotine cartridges for 12 weeks. The second group got e-cigarettes with 7.2-milligram cartridges for six weeks, followed by six weeks of lower-dose cartridges. The third group got cartridges with no nicotine for 12 weeks. All participants then came in for nine visits to report their cigarette use per day and get carbon monoxide breath testing.
Results showed that all groups—regardless of nicotine content—reduced their consumption of tobacco cigarettes over the course of the study. At week 52, 13% of participants in the first group, 9% in the second group, and 4% in the third group had quit.
But, obviously, there are some drawbacks here. First off, because the participants weren’t intending to quit, it’s kind of hard to call this a smoking-cessation study. Also, a considerable chunk of participants (40%) didn’t make it to the final follow-up. And as with most e-cigarette studies, the model of vape tested here isn’t current anymore, so we don’t know how well the results would generalize to other devices.
Another study, this one published later, in 2013, in The Lancet, followed 657 participants over six months. Participants were randomized to receive e-cigarettes, nicotine patches, or placebo e-cigarettes without nicotine. After six months, 7.3% of those who received the e-cigarette had quit smoking compared with 5.8% of those who received the patches and 4.1% of those who got the placebo e-cigarettes. The researchers concluded that “e-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches, and few adverse events.”
It’s reassuring that there weren’t many adverse effects associated with nicotine e-cigarette use in this study. Of those that did occur, about 80% were considered nonserious (compared with 88% nonserious in the nicotine patches group and 86% in the placebo e-cigarette group). But, again, we don’t the potential long-term side effects of using e-cigarettes.
More recently, a study published earlier this year in the New England Journal of Medicine compared the smoking-cessation potential of e-cigarettes with that of other nicotine replacement products. For the study, researchers randomly assigned 886 participants to receive three months’ worth of nicotine replacement products of their choice or an e-cigarette starter pack (and instructions to get their own e-liquid of their choice). Crucially, all participants also received weekly behavioral therapy for four months.
After a year, 18% of those in the e-cigarette group had stopped smoking, compared with 9.9% of those in the nicotine-replacement group. However, those in the e-cigarette group who had quit were far more likely to still be using their products at the one-year mark than those in the nicotine-replacement group who had quit. This underscores one of the crucial questions surrounding e-cigarettes as a smoking-cessation tool: If e-cigarettes do happen to help you quit smoking, when and how should you stop using the e-cigarette (if at all)?
Current thinking is that classic smoking-cessation methods should be helpful for quitting vaping like they are for quitting traditional smoking, but we don’t have evidence to show that’s true, Dr. Choi says. The strategies we have may need to be tweaked and tailored to be effective for vaping—especially for younger patients, he explains.
There’s also some evidence to suggest that vaping is actually more difficult to quit than smoking based on the amount of nicotine in the product and measures including the number of attempts users have made to quit, how long they’re able to go without a craving, and the severity of their withdrawal symptoms, Dr. Neptune says. There is contradictory research, however.
If you haven’t tried using other smoking-cessation methods, explore those first. But if you’ve already tried them or you’re not interested, what exactly are you supposed to do?
How bad is it to keep using legal e-cigarettes to keep you from smoking?
If it’s the only thing helping you stop smoking, can you just…keep vaping? This is where experts are divided. Again, the absolute safest thing to do is quit vaping. But understanding that approach isn’t feasible for everyone, harm reduction experts would encourage you to stay on the e-cigarette, provided that you’re an adult and it’s genuinely helping you stay away from traditional cigarettes.
“Evidence to date suggests that, despite all the hysteria right now, [e-cigarettes] are far less harmful than cigarettes,” Brandon says, even though, ideally, you wouldn’t be doing either. “I don’t think substance dependence is completely benign; it kind of controls your life,” he continues. “But I also think we have to keep in perspective that even if you do vape for the rest of your life, it’s way better than smoking.”
Public Health England famously (and controversially) estimates that e-cigarettes are about 95% safer than traditional cigarettes, mainly due to the lack of combustion. People may quibble about the exact number, Brandon says, but it’s generally accepted that traditional cigarettes are worse for you than e-cigarettes. Staying on an e-cigarette may not be the healthiest decision you could make, but it’s certainly healthier than smoking combustible cigarettes for the rest of your life.
“If you switched and you can’t stop using all nicotine products, there’s nothing wrong with staying on an e-cigarette if it’s the only way to prevent relapse,” Abrams says. So, if the question is vaping versus smoking, experts definitely don’t want you going back to smoking cigarettes.
Still, the lack of long-term safety data, mounting evidence of unexpected harms, and youth addiction potential of e-cigarettes has other experts worried. “Go to the tried-and-true [smoking-cessation methods],” Dr. Neptune urges. “This would be the recommendation even if we didn’t have the current scares about the vaping-related lung injury epidemic and deaths. [You] should not get discouraged—we have effective therapies for adults who want to quit.”
Whatever you do, don’t go back to traditional cigarettes.
Choosing the right course of action for you requires carefully balancing your treatment need with the known harms of cigarettes, the known risks associated with e-cigarettes, the other options for smoking cessation, and the fact that, clearly, we don’t know everything about vaping.
Whatever you do, don’t go back to traditional cigarettes, because there are known deadly harms associated with them. If you’re not sure what the best course of action is for you, talk to your doctor. “This is a good time for anyone who smokes or vapes to seek medical attention to have a discussion about treatment for nicotine dependence,” Dr. Choi says. “The treatment is individualized, there’s no one good way for everyone,” he continues. “This is a good time for people to have that one-on-one discussion with their doctor.” Often this is more of a “side topic” in a medical visit, but it’s okay to make it the primary reason to see your doctor—especially now, he says.
Above all, Abrams is worried that, by focusing on limiting access to legal nicotine vapes rather than tackling illegal THC vapes, we’re going to “destroy completely the biggest opportunity we’ve had in 120 years to eliminate deadly cigarette smoking,” he says. “That’s the biggest tragedy of the unintended consequence of this very well-meaning concern [about vaping].”
Going after flavored e-cigarettes rather than illicit THC-containing vapes—especially while traditional cigarettes are still on shelves—is like responding to shark attacks in the ocean by banning swimming pools, Brandon adds.
And if you’re frustrated with the lack of clear guidelines and lack of information about a product you might be addicted to, know that it’s not your fault. You shouldn’t feel ashamed or guilty, Dr. Neptune says, but you should make your voice heard. Talk to your doctor and the FDA so we can get the research and regulations we need to make actual recommendations based on evidence—not hysteria.