Voices on Vaping — Public Health Problem or Smoking Cessation Tool?
By Lindsey Getz
Social Work Today
Vol. 20 No. 3 P. 16

Perspectives differ on the utility of e-cigarette use. What do researchers and clinicians say, and how can social workers best implement a harm reduction approach?

Vaping is a complicated issue and one that social workers are struggling to navigate. On one hand, they’ve been told that vaping is a safer alternative to smoking and a possible path to smoking cessation for their clients with substance use disorders. However, with the Surgeon General declaring youth vaping an epidemic, there is justifiable concern, leaving social workers wondering whether they should continue to stand behind these “alternative” recommendations.

Vaping is the use of an electronic cigarette (also referred to as e-cigs, vape pens, or electronic nicotine delivery systems). E-cigarettes work by heating nicotine (extracted from tobacco), flavorings, and other chemicals to create an aerosol that is inhaled.

Vaughan W. Rees, PhD, director of the Center for Global Tobacco Control at Harvard T.H. Chan School of Public Health, has been conducting research to inform regulatory strategies to reduce harms associated with tobacco use, and evaluates new and novel tobacco products for their addictive potential. Rees maintains that vaping offers an alternative to adult smokers who are looking for ways to help them quit their use of a far more deadly product—combustible tobacco.

“There is evidence that shows vaping is associated with an increased likelihood of making cessation attempts and even successfully quitting compared to what is considered best practice of cessation interventions,” Rees says. “Currently the science tells us that vaping is a less risky alternative to smoking, but that’s not to say that we don’t need to keep it out of the hands of kids. I think we need to understand the science and communicate it in a less emotional way. Naturally, we get emotional when kids are involved.”

Though the Surgeon General’s recent declaration of a youth epidemic is alarming, the Centers for Disease Control and Prevention (CDC) maintains the position that e-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products. However, in terms of youth, the CDC has declared that e-cigarettes are not safe for youth and young adults—as well as pregnant women and adults who do not currently use tobacco products.

A Harm Reduction Approach
It comes down to a matter of harm reduction, says Lala Ashenberg Straussner, PhD, LCSW, a professor at the New York University Silver School of Social Work and an internationally recognized authority on clinical approaches to substance use disorders.

“There is a harm reduction approach to utilizing e-cigarettes as an alternative to smoking,” Straussner says. “From the research, it appears that vaping is less dangerous than smoking and, with what we know so far, seems to be a better alternative. Ideally, my recommendation would be to abstain from both. However, we know enough to understand it’s not that simple and we need to help our clients with a harm reduction approach. Ultimately, we’d like to see our clients transition from cigarettes to e-cigarettes to abstinence—but this is where social work assessments come into play. We need to help them through the process and understand what it is that they need to succeed.”

According to Rees, none of this information is exactly new—or changed. What social workers have already likely been telling their clients—that vaping is less harmful than cigarettes—is still supported by the latest science. But the climate surrounding vaping has changed considerably with concern rising, mostly in response to the outbreak of lung injury associated with the use of e-cigarette or vaping products—EVALI, an acronym for e-cigarette or vaping product use-associated lung injury. However, it’s important to be clear that, according to the CDC, data show that tetrahydrocannabinol (THC)-containing e-cigarette products—particularly from informal sources such as friends, family, or illicit black-market dealers—are linked to most of these lung injury cases. That outbreak resulted in 68 confirmed deaths and a total of 2,807 hospitalizations.

David Abrams, PhD, a professor of social and behavioral sciences at New York University College of Global Public Health, is concerned that EVALI has led to panic—and overwhelming misinformation. Abrams says that the tragic vaping deaths were linked to THC tainted with vitamin E oils, which can dangerously coat the lungs. According to the CDC, vitamin E acetate has been strongly linked to the outbreak and has recommended that vitamin E acetate not be added to any e-cigarette or vaping products.

But according to Abrams, the misinformation is rampant, and many are associating vaping (in general) with the deaths. Abrams fears that the rising call for prohibitionist measures could potentially lead to smoking deaths if smokers who have switched go back to smoking or never try to switch because they believe nicotine vaping is as dangerous as smoking.

“The statistics are clear that if smokers continue to smoke, they will be at increased risk of dying from smoking-related illnesses,” Abrams says. “I recently did a three-hour workshop with addiction treatment specialists, including social workers, and they want to know what to do; what is the latest information on nicotine? The answer is very clear. E-cigarettes are not completely safe, but they are significantly less harmful than combustible tobacco products. And the science is strong that e-cigarettes can assist in smoking cessation. In a randomized clinical trial, it was determined that e-cigarette use doubled the successful quit rate among smokers as compared to nicotine replacement therapy. Unfortunately, the science is being distorted and exaggerated for the prohibition agenda. But history and science have proven that prohibition simply does not work.”

Rees agrees and adds that some of the studies that have been utilized in support of the notion that e-cigarettes are undermining smokers’ health (or cessation efforts) have recently been called into question. In fact, in February this year, a peer-reviewed paper published in the June 2019 issue of the Journal of the American Heart Association, which reported that vaping could lead to a heart attack, has been retracted due to misleading analysis of the data.

“The argument of those who are pushing for stronger vaping regulations or even prohibition is that smoking is at a historic low and if we just continue what we’re doing, we’ll fix the problem,” Rees says. “However, while there is no doubt we’ve seen substantial progress, we have not seen progress in the same way among those of the lowest income brackets in our country. That includes those populations who have traditionally been thought of as underrepresented. In other words, while these policies and programs have worked for the more fortunate and more affluent, they have not helped those people who are very poor, have mental illness, or have other substance use issues. Vaping can provide alternatives to this population in support of smoking cessation.”

COVID-19 Concerns
During the interviewing and writing of this article, the COVID-19 pandemic became a public health crisis. Given that development, two sources were asked to comment on whether and how the virus may affect people who vape.

Abrams’ perspective: “There is no evidence that vaping per se makes one vulnerable to COVID-19. It is a premature and in my opinion irresponsible speculation. Rather, many years of smoking-related conditions that go with smokers who are now vaping will put those smokers at much higher risk. But it is from their other chronic conditions and smoking history, not from vaping. Of course this is a great opportunity for smokers to stop all use of tobacco or any nicotine product if they can. But harm reduction still applies. Smokers who are vaping should not go back to smoking. Vaping is still better than smoking but is of course not harmless.”

Rees comments: “It makes very good sense to acknowledge the potential link here. However, my message would not change at all: I would continue to prioritize concerns about smoking over those of vaping.

“There is abundant evidence that smoking causes chronic pulmonary damage, but the evidence that vaping causes such outcomes is scant at best. While there has been speculation that vaping is driving up complications in those with COVID-19 infection, I haven’t seen any attempt to distinguish the impact of past smoking in those cases.

“That is, most adult current vapers are former smokers and the complications that are being attributed to vaping are quite likely attributable to the chronic effects of smoking. The effect of former smoking is less likely to be a factor in adolescents, the majority of whom do not have a prior history of smoking. However, complications of COVID-19 is low in adolescents, with just 2% to 3% among those aged 19 and younger (which also supports the idea that other factors, including smoking, may be impacting complications).

“It is also worth noting that smoking rates are high in some of those countries with high COVID-19 death rates: China (~50% among men); Italy (24%); Spain (30%), etc. However, we simply don’t have enough detailed data yet to know whether there is an association between smoking and hospitalization or death due to COVID -19.”

Youth Vaping
While science continues to support vaping as a safer alternative to smoking among adults who already smoke, the CDC is clear that the use of e-cigarettes is unsafe for children, teens, and young adults. Most e-cigarettes contain nicotine, which is highly addictive. The CDC also contends that young people who use e-cigarettes may be more likely to smoke cigarettes in the future—though the research on this point has a way to go.

Abrams says, “We also see that the teens who are vaping are, or would have been, smokers. So vaping may be displacing smoking in otherwise-smokers more than it is promoting smoking in teens naïve to smoking. The most recent National Youth Tobacco survey of 2018 shows that 89% of teens who vape regularly were or are smokers. More importantly, teen smoking rates have gone down much more rapidly during the years vaping increased the most, suggesting a harm reduction effect for teens as well as adult smokers.”

“I think the biggest health risk among kids who vape is the development of nicotine dependence,” Rees says. “While we know that suggesting EVALI was connected with nicotine vaping was a case of misrepresented science, I do think that we still need to be aware of whether vaping is leading to an uptick in the number of kids using vaping products who might not have picked up smoking. Naturally, that is hugely concerning to parents.”

Kara Tierney-Trevor, LCSW, school social worker for South Portland High School in Maine, says that vaping among kids who otherwise might not have smoked is a serious concern. She says that vaping is “not a problem with a handful of kids in the corner vaping secretively.” She says that it is a problem “across the board”—including the athletes and honor roll students at her school.

“Based on talking to kids at the high school, it’s obvious that this is the new trend—and that most kids perceive it as safe,” Tierney-Trevor says. “These devices can be stored in their pockets and charged on their iPads, so it’s happening in school every day. It came to light that kids were leaving magnetic vaping devices underneath the toilet and texting one another as to where they could go to take a hit. This problem is growing quickly—and it’s uncharted territory.”

Dorian Fuhrman, cofounder of Parents Against Vaping e-cigarettes (PAVe), has similar concerns. Fuhrman started the grassroots organization with two other New York City moms after they discovered that a vaping company had sent a representative into their children’s school and promoted their vaping products as totally safe and about to get FDA approval—neither of which were true.

“Vaping affects all kids—the athletes, the honor students, the risk takers, the theater kids—everyone,” Fuhrman says.

Fuhrman echoes Tierney-Trevor’s sentiments about “uncharted territory,” and says that the organization has spoken with pediatricians who admit they’re not sure how to handle nicotine addiction among children.

“It’s the Wild West in terms of how you treat this,” she continues. “You have pediatricians suggesting nicotine gum or even considering antidepressants. And you have kids who want to quit but say they can’t.”

Fuhrman and PAVe had been among those advocating for the regulation of flavors, which she sees as an enormous part of the problem.

“It’s hard to deny that flavors like bubble gum or cotton candy aren’t being marketed directly to kids,” Fuhrman says. “It sounds safe because it’s candy. But these flavors have hooked kids. It has allowed harsh nicotine to be delivered in a smoother, cooler fashion. At PAVe we have advocated for the removal of all flavors.” Fuhrman says there is no conclusive evidence that adults need flavors to switch from smoking to vaping and that some of the studies that point to the fact that e-cigarettes might help smokers switch from traditional cigarettes to e-cigarettes do not document the role, if any, of flavors, but this has not been independently verified.

In January, the FDA removed some, but not all, flavored e-cigarette products from the US market in an effort to “prioritize enforcement against certain unauthorized flavored e-cigarette products that appeal to kids, including fruit and mint flavors.”

Rees believes the regulation of flavors makes sense—with some contingencies.

“I don’t see why we need hundreds of flavors including candy flavors that are clearly being targeted to young people,” Rees says. “However, I think that policymakers have gotten swept up in the passion of regulation and have been short-sighted by banning menthol and mint flavors because there is a significant portion of adult smokers—particularly those of low-income backgrounds—that use mentholated cigarettes. It is likely that menthol-flavored e-cigarettes provide a way to help a substantial proportion of smokers transition from smoking.”

While Straussner has concerns about young people trying vaping, she says that overexaggerating youth vaping creates its own set of problems.

“There is some hysteria surrounding this, and that can be problematic because it can cause us to overlook the science,” Straussner says. “Teens have always been susceptible to peer pressure and vaping happens to be the current ‘in-thing.’ But every generation has had their own set of substance issues. We don’t currently know the conversion of kids who are just experimenting with it to those who become regular users. There have been interesting studies looking at the progression into chronic addiction and we know that part of it is peer pressure, but it is also family relationships and underlying mental health problems.”

Like the others, Straussner is in favor of limiting flavors and says that social workers can play a role in thoughtful regulations.

“Social workers can help encourage policies that promote healthier and safer alternatives to smoking,” Strassner says.

Rees agrees. “Social workers are such an important piece of this issue, and it is so important that they have all of the information,” he says. “The best position right now is that, if used responsibly among adults who are already smokers, vaping can be a way to help vulnerable adults to quit their use of a vastly more dangerous combustible smoking product.”

— Lindsey Getz is a Royersford, PA-based freelance writer.