Is Vaping an Effective Form of Harm Reduction?

By Linda Richter PhD 11/05/15

Although vaping nicotine may be safer than smoking traditional cigarettes, it is still addictive and carries significant risks.

Is Vaping a Form of Harm Reduction?

As I was preparing to deliver a presentation on the opioid epidemic, I wondered how the loss of life caused by opioid overdose compares with fatalities due to other substance misuse. After all, the current painkiller/heroin situation is commonly referred to as the “worst drug epidemic in U.S. history.” The fact is that the number of deaths attributable to opioid overdose (around 25,000) is relatively small compared to those caused by alcohol (almost 100,000), and cigarettes are by far the most deadly form of substance use, with a U.S. death rate of almost 500,000 people per year. An interesting question arises from the growing popularity of vaping, where nicotine is delivered sans tobacco smoking: Should vaping be construed as a legitimate harm reduction technique, in that it reduces most of the smoking-caused harm from nicotine, thereby allowing people who are dependent on nicotine to use it without the attendant dangers involved in smoking cigarettes? Should addiction treatment professionals encourage clients to vape, rather than smoke? Dr. Linda Richter, from the Center on Addiction and Substance Abuse and Columbia University, says no…Dr. Richard Juman

Daily news stories documenting the risks and benefits of electronic cigarettes and other nicotine delivery systems (“vaping devices”) can leave a person wondering whether such products are just another incarnation of the deadly cigarette, or whether “vaping” is a relatively risk-free means of getting a nicotine fix or even a medicinal cure for those addicted to smoking. While there is not yet a robust body of evidence documenting all the risks and benefits of alternative or non-cigarette nicotine products, there is sufficient evidence to treat these products with caution. Nicotine, regardless of its means of delivery, is not a harmless drug. 

The good news is that we’re finally talking seriously about nicotine. In a 2013 article in the American Journal of Public Health, my colleague, Susan Foster, and I argued for increased attention to nicotine as an addictive substance that too often was excluded from addiction-related policy, research, and clinical practice. Although nicotine still is not addressed in substance-related prevention and treatment to the same extent as alcohol, illicit drugs, and controlled prescription drugs, the increasing popularity of non-cigarette nicotine products is prompting a long-overdue discussion about nicotine.

There is little dispute that electronic cigarettes and other electronic nicotine delivery systems that do not contain tobacco leaves are safer than conventional cigarettes. Although they lack the by-products of smoked tobacco, that does not mean that these products are safe. To the contrary, they are delivery systems for the highly addictive drug nicotine, use of which can result in serious health consequences including the disease of addiction. 

Nicotine use is associated with an increased risk of tobacco, alcohol, and other drug use and with addiction involving these drugs. Nicotine also affects the nervous, cardiovascular and respiratory systems and there is some evidence that it may contribute to cancerous tumor development. It is associated with preterm delivery and stillbirths, and exposure to nicotine during fetal development and adolescence has lasting adverse effects on brain and lung development. Electronic cigarettes and vaping devices also contain a host of potentially toxic chemicals, including those that make up the flavorings that help attract current smokers, as well as appeal to children and teens who have never smoked cigarettes. 

Despite industry claims that these products are intended only as safer alternatives to conventional cigarettes for existing smokers, two facts are clear. First, their use among young people, many of whom have never smoked traditional cigarettes and many of whom have expressed no interest in doing so, has tripled in recent years. Not only are young non-cigarette smokers using these products, but recent research also shows that a significant proportion of them who demonstrated no prior intention to smoke ended up starting to use regular cigarettes after having used electronic cigarettes. Once kids start using these products—which may be more enticing to use than conventional cigarettes because of their appealing flavors, paraphernalia, and lower social stigma—they are exposed to potentially large doses of nicotine and its addictive properties. They also begin to develop the sensory and behavioral habits associated with using nicotine products that can easily be transferred to conventional cigarette use—the most potent and deadly nicotine delivery system.

Second, electronic cigarettes and other nicotine products increasingly are being used in conjunction with, instead of in place of, tobacco cigarettes. Few would disagree with the idea that it is preferable for a long-term adult cigarette smoker to switch to electronic cigarettes to help cut back on and eventually quit smoking if he or she has been unable to quit using approved smoking cessation aids. But research is finding that a significant proportion of electronic cigarette users are dual users, continuing to smoke cigarettes while using other nicotine products. These users are increasing their exposure to nicotine and the numerous toxic chemicals contained in tobacco and nicotine products. 

In the face of the documented risks and the uncertainty of the benefits of electronic cigarettes and other vaping devices, one would expect the U.S. Food and Drug Administration (FDA) to place restrictions on the manufacture, marketing, and sales of all nicotine products, but that has not yet happened. Because the FDA does not currently regulate non-tobacco nicotine products, the amount of nicotine these products contain can vary widely, in some cases exceeding the nicotine doses of conventional tobacco cigarettes. And, unlike conventional tobacco cigarettes, there are no federal regulatory restrictions on the inclusion of appealing flavors in these products, which play a pivotal role not only in attracting current cigarette smokers, but also young people who have never smoked a cigarette and had no intention of doing so. The lack of any significant federal restrictions on these products means that their promotion on television, other media, and in point-of-sale advertising has become commonplace, reviving many of the cigarette companies’ old marketing strategies that strongly appeal to youth and other vulnerable populations.

Research findings increasingly are highlighting the importance of a science-based approach to the regulation of all nicotine-containing products. To focus public attention on this research and to provide a thorough account of the current state of knowledge about nicotine, my colleagues and I at CASAColumbia® recently released a paper, Understanding and Addressing Nicotine Addiction: A Science-Based Approach to Policy and Practice. This report summarizes the evidence regarding the prevalence and correlates of nicotine use and addiction, the effects of nicotine on the brain and body, the risk factors for nicotine addiction, the groups most at risk, current prevention and treatment efforts, and the implications of this research for policy and practice. Another report on the specific types of alternative tobacco or nicotine delivery systems, like hookah and electronic cigarettes, will be released later this winter. 

As our newly published paper demonstrates, the available research clearly is sufficient to support action by the FDA, as well as state and local governments, to protect young people from the harms of nicotine and other addictive substances. Public health and policy efforts have been remarkably successful in reducing rates of cigarette smoking in the United States over the past few decades. However, the commercial interests of the tobacco industry, which are increasingly taking over electronic cigarette companies, demand that more immediate action be taken. We cannot afford to become complacent in allowing alternative nicotine products to undo decades of hard-won progress. If we wait another decade before we act for even more evidence regarding the harms and benefits of these products to be revealed, we risk repeating the mistakes of the past at significant risk to public health.  

Linda Richter, PhD, is the Director of Policy Research and Analysis at CASAColumbia. Her work focuses on examining policies that can help integrate addiction care into mainstream medical practice, educating the public and health professionals about evidence-based addiction care, translating the science of addiction for lay audiences, and improving substance use and addiction prevention and treatment, particularly among young people.

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Linda Richter, PhDis the Director of Policy Research and Analysis at CASAColumbia. Her work focuses on examining policies that can help integrate addiction care into mainstream medical practice, educating the public and health professionals about evidence-based addiction care, translating the science of addiction for lay audiences, and improving substance use and addiction prevention and treatment, particularly among young people. Find her on Linkedin.