Hawaii Health Alert: Is Vaping Really Better Than Smoking?

E-cigarettes can leave carcinogens in your blood and may double your risk of heart attack.

Hawaii Health Alert: Is Vaping Really Better Than Smoking?

Millions of Americans use e-cigarettes regularly, and the number of vapers in the United States is on the rise, particularly among young people. Vaping has become so prominent in Hawaii that sitting in gridlock on the H1 may smell more like fruity vapors than car exhaust from so many drivers vaping with open windows.

The worrisome trend prompted the U.S. Surgeon General Vice Admiral Jerome M. Adams, MD, MPH, to issue an advisory on the e-cigarette epidemic among American youth on December 18, 2018. The statement asked all Americans to help protect children against a lifetime of nicotine addiction.

“We need to protect our kids from all tobacco products, including all shapes and sizes of e-cigarettes,” Dr. Adams says. “Everyone can play an important role in protecting our nation’s young people from the risks of e-cigarettes.”

The national percentage of high school-age children who report using e-cigarettes within the past month surged by more than 75 percent between 2017 and 2018, according to the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration’s National Youth Tobacco Survey. Meanwhile, vaping among middle schoolers also increased by nearly 50 percent.

Vaping among teens, specifically high school seniors who admit to using e-cigarettes sometime within the past year, jumped from about 28 percent to 37 percent between 2017 and 2018, according to the U.S. National Institutes of Health 2018 Monitoring the Future survey, a program that tracks substance abuse trends among young people.

The problem in Hawaii is even more severe—our state has the third-highest vaping rate in the country. According to the Hawai‘i Public Health Institute, which runs the Coalition for a Tobacco-Free Hawaii, 25 percent of local high school students and 15 percent of middle school students vape. In 2017 alone, 42 percent of Hawaii’s students admitted to at least trying some form of electronic smoking device, according to the Hawai‘i Health Data Warehouse.

E-cigarettes have been controversial ever since they came to the United States in 2007, touted as a safe way to quit smoking. Shortly after their arrival, the World Health Organization (WHO) announced that there was no evidence that e-cigs were safe or an effective way to stop using tobacco. And in 2016, the WHO officially recommended countries restrict their use.

Still, there's confusion about e-cigs' general safety, as well as their efficacy as smoking cessation aids.

What are e-cigarettes, exactly? 
The “e” stands for “electronic”—standard “e-cigs” run on a battery and have a chamber for storing liquid that usually contains nicotine. You don’t light them, and they don’t produce smoke, the most dangerous aspect of ordinary smoking. Instead, when you puff on one, your lungs take in vapor, a heated mist, which is why smoking e-cigs is also referred to as "vaping."

An e-cig can look like an ordinary cigarette, cigar or pipe, or like a pen or USB stick. It might be called a "JUUL," “e-hookah,” “mod,” “vape pen,” “vape,” “tank system” or “electronic nicotine delivery system (ENDS).”

About 14 percent of teens who vape admit they don’t know what’s in their e-cigarette, according to the U.S. National Institute on Drug Abuse (NIDA). This isn’t surprising as e-cig manufacturers aren’t required to list ingredients. Nearly 6 percent of teens think they are vaping marijuana, the agency notes. Meanwhile, 13 percent of teen users know that their e-cigarette has nicotine in it, but a staggering 66 percent think it only contains flavoring. A majority of teens (60 percent) believe that using e-cigarettes causes little to no harm.

How safe is vaping?
Although vaping initially appeared safer than smoking tobacco, new and increasingly alarming developments are coming to light. Most worrisome: In 2019, hundreds of e-cigarette users across the U.S. were hospitalized for severe lung disease linked to the habit.  

While experts are still learning about how vaping affects health, they do know of some specific dangers. “There’s no question that e-cigarettes cause inflammation of the airways and chronic bronchitis,” says Norman H. Edelman, MD, Senior Scientific Advisor to the American Lung Association. Most e-cigs contain nicotine, which is highly addictive, toxic to developing fetuses and can harm adolescent brain development, the CDC reports. Dr. Edelman adds that vaping nicotine increases blood pressure and “there’s new data that nicotine promotes lung disease and lung cancer,” he says.

In addition to nicotine, e-cigs contain other chemicals, like kid-friendly flavoring and benzene, that may be dangerous. One 2018 study found higher levels of five cancer-causing toxins in the urine of 16-year-old e-cig users. Another 2018 study, presented at a conference hosted by the Society for Research on Nicotine & Tobacco, found people who vaped daily had almost double the risk of heart attack compared to those who didn’t vape. Other research suggests that vaping makes germs like staph more resistant to drugs.

How is vaping regulated?
Beginning in August 2016, the federal Food and Drug Administration (FDA) set a national minimum legal sale age of 18 and forbid free e-cig samples, which had been distributed at music and sporting events. In Hawaii, the minimum age to purchase e-cigs is 21. As of August 2018, e-cigs containing nicotine must bear a warning that the compound is addictive.

According to some, however, FDA regulators are moving too slowly. In March 2018, multiple major public health organizations, including the American Heart Association and American Academy of Pediatrics, sued the agency for delaying its safety review of e-cigarettes and cigars. Because of the lull, products appealing to young people are still available for purchase, such as “Smurf Sauce,” “Unicorn Cakes,” and chocolate-flavored e-cigarettes.

Some experts believe those products may lead those minors to regular smoking. In 2018, two studies did find that teens move on from e-cigs to ordinary cigarettes—but Edelman thinks the question remains unresolved.

What are Hawaii’s vaping laws?
Tobacco and nicotine laws are the same for cigarettes and e-cigs in Hawaii. That means it is illegal for anyone under 21 to purchase or even possess e-cigs. Unfortunately, 808 No Vape, part of the Coalition for a Tobacco-Free Hawai‘i, claims that 94 percent of attempted online e-cigarette purchases by Hawaii teens have been successful.

Furthermore, laws governing where individuals can smoke are the same for vaping. It is illegal to vape at restaurants, stores and most public parks and beaches. Violators may be subject to fines depending on the city and county of the infraction. Private citizens have the right to contact police if they spot anyone vaping in protected areas.

Does vaping help smokers quit?
E-cigarettes are not an FDA-approved smoking cessation aid since the evidence on the issue is mixed. On one hand, a 2019 study in the New England Journal of Medicine found, when used as part of a structured quit program, e-cigarettes may be more effective than nicotine replacement therapy. On the other hand, a 2017 CDC briefing concluded that smokers were more likely to swap in e-cigarettes rather than use a patch or gum, but most didn’t quit smoking entirely. Instead, they end up as “dual users.” And in 2015, among U.S. adult e-cigarette users, nearly 59 percent also regularly smoked. Only about 30 percent were former smokers.

Teens are more likely to use e-cigarettes than adults, and boys vape more often than girls. But once they try e-cigarettes, all teen users are actually more likely to start smoking within six months, NIDA reports.

Bottom line: It’s best to quit smoking entirely and e-cigs could make that harder. “Vaping actually makes it less likely that smokers will quit by about 27 percent,” says Stanton Glantz, Director of the University of California, San Francisco Center for Tobacco Control Research and Education.

Medically reviewed in January 2019.

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