by Andrew Bell
What you can do:
- Recognize that e-cigarettes are at least as harmful as traditional cigarettes and consider the evidence of their health effects before using them.
- Become an advocate in your own social circle against using harmful nicotine delivery devices, and be a positive, rather than a negative influence.
- Support your friends and loved ones who may be suffering from any kind of substance abuse disorder, including nicotine-related disorders.
- Weigh information in advertisements carefully, and consult evidence-based research before forming an opinion on the safety of a particular drug.
One of the things our generation can be most proud of is that, compared to all earlier generations, the rate at which millennials and Generation Z smoke traditional tobacco cigarettes has decreased markedly. This, we were told, was the grand finale of a societal war on nicotine meant to free young people from the grasp of an addictive toxin. After many years of an onslaught from the Federal Drug Administration against the principal product of big tobacco companies such as Altria, British American Tobacco, or Phillip Morris, including heart-tugging PSAs, television commercials, and labeling legislation, it seemed for some time that our generation might finally have been the one to overcome the burden of nicotine that had plagued our predecessors for generations. Unfortunately, we’re now seeing signs of an eleventh-hour comeback by nicotine – and worse, we’re not even all that concerned about it.
Almost every young person today has had some sort of interaction with electronic cigarettes, which are slowly but surely becoming more ubiquitous in popular culture. Even if not everyone owns an e-cigarette (colloquially known as a “vape”), most of us probably know someone who does. Among students, the positive perception of these nicotine delivery devices is on the rise. This change in perception alone is associated with negative health outcomes. In fact, the mere perception that e-cigarettes are significantly less harmful or less addictive than traditional cigarettes has been found to increase students’ odds of lifetime nicotine use.  Ironically, products originally designed for the very purpose of reducing people’s dependence on traditional cigarettes have not only failed to do so, but may be having the polar opposite effect. In another study, researchers found that the reduction in likelihood of lifetime nicotine use brought upon by the (largely successful) federal labeling program – the laws requiring cigarette companies to print those black-and-white warning labels on their boxes – was significantly diminished by exposure to e-cigarette advertising.  These advertisements tend to claim that their product has been proven to help smokers quit – a claim that has never been empirically demonstrated and has in recent years been soundly disproven.   The science is out, and the evidence speaks for itself: e-cigarettes are no more effective than traditional cessation techniques, nor were they ever intended to be. The claims in advertisements were intended only to convince what was once an unwilling generation to give nicotine a chance – after all, they weren’t bad like cigarettes.
If e-cigarettes aren’t good for quitting smoking, what can they do? All sorts of things – but none of them good. Young people in particular tend to think that e-cigarettes are much safer than traditional cigarettes – that they have a much lower risk for addiction, cancer, lung disorder, heart disease and other side effects that have long been associated with long-term cigarette use.  Bear in mind that this perception alone contributes to an increase in the likelihood of long-term nicotine use, both via e-cigarette and traditional cigarettes. Even more worrying is the fact that none of it is true. While it is correct that long-term research into the harmful effects of e-cigarettes is still in its infancy, much research has been performed which demonstrates a strong relationship between e-cigarette use and poor health outcomes. First and foremost, e-cigarettes are addictive – no ifs, ands, or buts about it. Several studies have demonstrated strong relationships not unlike those seen in traditional tobacco use; for instance, one study found that exposure to e-cigarette chemicals besides nicotine in mice prompted typical reward-center activation in the brain and stereotyped addictive behavior.  It’s worth repeating that this study only analyzed common components besides nicotine – these effects are over and beyond the well-documented addictive properties of nicotine itself, which is typically a main component of e-cigarette liquid. Considering cardiovascular effects, the evidence suggests that electronic tobacco products aren’t much – if at all – safer than the original. In one such study, e-cigarette users were found to exhibit significantly higher signs of oxidative stress (a measure of cell damage) in heart tissue in comparison to nonusers.  Furthermore, many of the most harmful cardiovascular toxicants in cigarette smoke – such as formaldehyde, acetaldehyde, acetone, acrolein, and butanol – are present in e-cigarette vapor. These chemicals have the effect of increasing resting heart rate and blood pressure, while promoting blood vessel damage and blood clots.  Perhaps more notably, the same study found that nicotine itself has similarly harmful cardiovascular effects. E-cigarettes are also no less harmful when carcinogenic effects, lung damage, or other consequences are considered. For instance, users are exposed to comparable levels of carcinogens and toxins such as heavy metals (the cause of the “oxidative stress” mentioned above), formaldehyde and acetaldehyde (the same chemicals that act as cardiovascular toxins), and others, which have been shown in animal studies to impair lung tissue growth and function.  Interestingly, the same study found that e-cigarette users are actually less likely to quit smoking cigarettes than smokers who did not use e-cigarettes.
It’s clear that e-cigarettes are harmful to users’ health – perhaps just as much so as are traditional cigarettes. Why then, do they continue to see a rise in popularity, particularly among the young cohort which was expected to break the grasp of the tobacco industry? Aside from the obvious answer that nicotine is no less addictive coming from a metal tube than from burning paper, our society has continually failed to live up even to the meager standards of the war on tobacco. Labeling regulations for electronic delivery systems have still not yet caught up to those applied to traditional cigarette brands, despite the fact that most e-cigarette companies are owned by tobacco companies.  Restrictions on cigarette advertising under the Tobacco Control Act (such as, for instance, a law banning most forms of promotion of cigarettes in television commercials) are almost wholly absent from e-cigarette products, which are freely shown on posters and commercials nationwide.  Additionally, there has been a strong tendency, particularly among adolescent users, to deny that they face the same risk of negative health outcomes – a finding not unlike the tendency for marijuana users to underestimate their own risk for the same, relative to their peers.  Despite the lower perceived risk of health consequences, younger people who hold such beliefs are nonetheless more likely to progress to traditional smoking and suffer negative health outcomes versus those with a greater appreciation for the associated health risks.  Taken together, these findings provide evidence for the efficacy of targeted legislation to limit the sales of e-cigarettes to young people and to reduce their ability to appeal to children and adolescents, who are disproportionately more likely to begin using nicotine via sweet or candy-flavored e-cigarettes. 
There is also the issue of motivated cognition among users of e-cigarettes when confronted with the chemical realities of the compounds in these products. In general terms, motivated cognition occurs when a person erroneously modifies a thought process in order to justify or reduce anxiety about a particular stressor – such as information that one of their choices is considerably harmful to their physical well-being. The typical manifestation of motivated cognition with nicotine and other commonly abused drugs, which plagues even the most well-conducted empirical studies, is the systematic tendency of users to underreport their frequency of nicotine use. Participants rarely consciously lie but are instead influenced by unconscious drives to appear “better” in the eyes of an examiner. In the context of e-cigarette studies, biological markers – chemicals which can signal that which a person does not consciously admit to – are used to control for these effects. In one such study, cotinine, a metabolic derivative of nicotine, was measured in smokers’ saliva. Simply put, a higher level of cotinine indicates more frequent ingestion of nicotine, and the levels of cotinine were predictive of nicotine exposure.  Therefore, testing for the presence of this chemical can definitively assess one’s nicotine intake even if they are unlikely to admit to it verbally. Such studies have found that nicotine users are likely to underreport their overall intake.  Worse still, these effects are magnified for younger populations. This is a significant problem, because it suggests that even frequent users of e-cigarette products aren’t actually cognitively aware of how much they are using, nor are they aware of the severity of the negative health outcomes that are associated with use. This contributes to the recognizable phenomenon of chronic users passionately denying that they have a problem – one of the hallmarks of a substance abuse disorder. Clearly, from both a medical and psychological perspective, the phenomenon of e-cigarette use is inherently complex and requires a multi-faceted approach to combat.
Fortunately, all hope is not lost. We are, after all, the generation which finally struck a major blow to traditional tobacco; if current trends hold, the industry will not be sustainable in the coming future. However, we must take care to ensure that we are not merely replacing one evil with another – one that is at least as dangerous as the first. While certain legislative actions such as those mentioned above have been successful in reducing smoking rates, they have not been faithfully applied to their new incarnations. Furthermore, it is becoming more and more clear that e-cigarettes enjoy a certain social classification that is not currently extended to traditional cigarettes. It is not uncommon at social gatherings among younger populations for groups to share vape pens; such activity using traditional cigarettes would likely seem outdated at best, and odd all the same. This puts an additional prerogative on all of us – not just as young people, but as future leaders, and the next generation of decision-makers who will decide for ourselves and our descendants if eradicating nicotine abuse is really something we care about. We must deny nicotine – in any form – the social benefit it relies on to reach larger audiences. This is not to say we should shun people using a vape, but we should be unafraid to discuss our concerns with close friends and family members, in the same way we would for any other medical situation. It’s true that in many cases, such interactions may result in defensive reactions or awkward moments, but we must come to understand that those moments are surely better than another addiction epidemic and another generation of corporate giants profiting off the health declines of entire populations. And we must continue to support our friends and loved ones who are working through addiction. If we can do this, our generation may yet be known as the slayer of the nicotine giant. In times like these when we could really use a win, I can think of no greater honor.
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Photo credit: https://blog.nemours.org/2019/09/e-cigarettes-teen-use-reaching-epidemic-proportions/