Should we be worried about vaping? – Expert Q&A

Over a dozen people have died in the United States and another 800 have become seriously ill in an outbreak of lung injury that appears to be associated with vaping.

The US Centers for Disease Control and Prevention (CDC) has confirmed 12 deaths, although media reports suggest up to 17 people have died. The CDC is continuing to investigate the deaths and illnesses, and says all patients have reported using e-cigarettes, with three-quarters saying they vape THC-containing products.

While the investigation is ongoing, the CDC recommends people refrain from using e-cigarettes, especially those containing THC. So far, no single substance has been identified in all the samples tested, though Vitamin E acetate has been found in many of the samples containing THC.

The SMC asked experts about the current situation and the benefits of vaping for smoking cessation.

Dr Penny Truman, School of Health Sciences, Massey University

Conflict of interest statement:

• I am a member of End Smoking New Zealand, which advocates for harm reduction solutions (such as e-cigarettes) to be encouraged within tobacco control policies.
• I have been part of the MoH technical advisory group on e-cigarette regulation (2018).
• I have an MBIE-funded Endeavour grant to work towards developing better smoking cessation therapies.
• I am not and never have been funded by the tobacco industry or the vaping industry, either directly or indirectly.

Dr Natalie Walker, Associate Professor in Public Health, The National Institute for Health Innovation (NIHI), School of Population Health; Director, Centre for Addiction Research, Faculty of Medical and Health Sciences, The University of Auckland

Following a number of deaths in the United States linked to vaping, what do we know about the possible cause? Should New Zealand vape users be concerned?

“The US outbreak of severe, acute respiratory failure (including deaths) related to vaping is certainly of concern. An investigation into the cause of these events is on-going so nothing is as yet certain.

“Whilst the investigation is underway, government agencies in the US are recommending consumers avoid buying vaping products from the black-market, and to refrain from vaping THC oil (THC is Tetrahydrocannabinol – the main psychoactive ingredient of cannabis) or ‘modifying/adding any substances to products purchased in stores’.

“We need to put these events into context. First, e-cigarettes have been around for more than a decade, with no indications of harm. Second, the recent US events appear to be acute, that is they don’t appear to be related to long-term vaping. Finally, in the USA, 480,000 people die each year from smoking-related diseases (that’s 1,300 deaths every day) – it’s a pity these deaths don’t also make the world news.

“Should New Zealand vapers be concerned about the serious vaping events in the US? At this stage there is no evidence of the issue occurring in New Zealand, but I would suggest vapers make sure they buy their vaping products from reputable retailers and should not vape THC oil.”

How have different countries approached regulation of e-cigarettes and their liquids? Would further regulation help protect vape users against these potential risks?

“It’s an incredibly complex topic, and product regulation varies greatly around the world. Currently: 32 countries regulate nicotine concentration/volume, 32 countries prohibit use of harmful ingredients (except nicotine) in e-liquid, 31 countries regulate quality of e-liquid content, require safety and quality evaluation or regulate flavors in e-liquid. See the full list of countries here.

“What New Zealand’s e-cigarette product regulation will look like has yet to be debated. However, product regulation should always be stronger for smoked tobacco. The recent vaping-related health events in the US have highlighted how important it is that vapers don’t purchase e-liquid from the black market (given you can’t guarantee the quality of the product) – and to only buy from reputable retailers.”

Is vaping a useful tool for people trying to quit smoking? What do we know about possible harm compared to smoking?

“Not all people find vaping helps them quit smoking, but for some vaping is the only thing that works. The most important thing is to stop tobacco smoking, as it’s incredibly harmful. Nicotine e-cigarettes and nicotine replacement therapy (NRT) are reduced-harm nicotine products. These products are not without harm, but they are less harmful than continued use of tobacco.”

Are there any current restrictions – in New Zealand or elsewhere – about how these products can be marketed? How should marketing of these products be managed?

“Again it’s an incredibly complex topic, and marketing regulations for e-cigarettes vary greatly around the world. According to Global Tobacco Control, currently: ’67 countries prohibit or regulate advertising, promotion, or sponsorship of e-cigarettes and eight of these countries apply the advertising restrictions only to e-cigarettes that contain nicotine or that are regulated as medicines’.

Given the current state of knowledge, is it recommended that smokers use vaping to quit tobacco? What about non-smokers?

“There are a number of approved pharmaceutical treatments available to support people who want to quit smoking, including nicotine replacement therapy (e.g. nicotine patches, gum, lozenges and mouth spray), bupropion (Zyban) and varenicline (Champix).

“E-cigarettes (with and without nicotine, or used in combination with nicotine patches) are another option, but they are not a medically-approved quit smoking medicine. There is clinical trial evidence to support the effectiveness and safety of all of the above options. Non-smokers should not vape.”

No conflict of interest.

Professor Julian Crane, Director, Wellington Asthma Research Group, University of Otago Wellington

Following a number of deaths in the United States linked to vaping, what do we know about the possible cause?

“Exact causal agent or agents not yet known. 80% of cases (out of 215 as at late August) had used both nicotine and THC and CBD (cannabinoid products) and some vitamin E acetate oil – as a carrier.

“Lung pathology is variable but often involves various forms of acute lung damage but different pathology suggest possible multiple causative agents

“Sporadic cases have been reported since 2014 usually associated with inhaling oily compounds

“As of 1 Oct, The Guardian reports 800 cases of lung problems and 13 deaths.”

Should New Zealand vape users be concerned? 

“Yes but not so much that they return to smoking. It is important only to use standard e-cigarettes and their specific solutions without adding anything to them. In general it is much better not to use flavourings if possible. Some 6000 are now used in e-cigarettes and while most pass food standards none have ever been tested on the lung – this is a tragedy waiting to happen – and it looks like it has!”

What do we know about possible harms of vaping compared to smoking?

“We know that smoking does a lot of harm so likely to be less than smoking

Do we have enough evidence to know how vaping may affect users’ lungs?

“No, obviously the long-term effects will take a long time to appear and hopefully the acute lung problems will be clarified and the offending agents removed.”

Given the current state of knowledge, is it recommended that smokers use vaping to quit tobacco?

“Yes, but they should only use approved e-cigarettes and their various specified components.

What about non-smokers? 

“No it is sad to see the way they have been marketed at youth who should not be using them.”

No conflict of interest.

Dr Sommer Kapitan, senior lecturer of marketing, Auckland University of Technology

Are there any current restrictions – in New Zealand or elsewhere – about how these products can be marketed? How should marketing of these products be managed?

“In New Zealand, the marketing, promotion, sales and use of vapes is unregulated. This means that advertising and promotion material can be targeted at everyone, whether they are smokers or not. That is dangerous, and highly worrisome. We have seen these tactics before. Clouds of vape, vapes held in hands by young professionals, vapes in use at youth-driven music festivals. Replace this imagery with a lit cigarette, and this looks like big tobacco all over again.

“Unlike other highly-regulated nicotine-delivery devices such as cigarettes, vape advertising and promotion material is aired on public television commercials, shown on billboards along busy streets, found on posters inside cinema toilet stalls, and plastered all over Instagram and other social media. It is clear that the lack of regulation around vape marketing efforts has resulted in the promotion of vaping not merely as a smoking cessation tool, but as a lifestyle choice. Vape marketing materials on websites and social media shows women dancing, people on boats enjoying cool flavours, a vape in hand while waiting for the train, a sleek vape alongside a morning coffee (#morningsmade). Commercials show sleek, stylish and high-tech vape pens with bright colours and catchy, upbeat music. Influencers on social media blow vape rings or exhale big clouds of vapour, and Rhythm & Alps festival-goers pose topless or in big groups around life-size frames with vape logos, sharing imagery of a vaping lifestyle to all their friends, followers, and the general public.

“None of this marketing and advertising emphasises ‘smoking cessation’. The job of marketers is to cultivate an audience, convince them to try their product, and ultimately to sell. Marketers of vape products in New Zealand are just doing their jobs. They are operating as they should in aiming to grow profits – and they are targeting nonsmokers as well as smokers who might like their nicotine products. Yet regulators in New Zealand are not yet doing their jobs to protect the public from a lifestyle choice that involves highly-addictive nicotine and otherwise questionable or unknown side effects.

“Vaping might be less risky than cigarettes for smokers. But vaping is clearly risky for nonsmokers adopting the trend.

“Currently in New Zealand, vapes can be bought and sold freely in any commercial marketplace that chooses to sell the devices. Under national law, vapes can be used in most public places, from bars and restaurants to public transit, street corners, public parks, schools and daycare centres. It has been up to each individual region, business or municipality to legislate the use of vapes in their establishments. For instance, vaping and smoking are not allowed on AUT’s campus or in Auckland parks. Unlike cigarettes, which draw both a moral response and a host of regulations about usage, vaping in all areas of public life is generally welcomed under New Zealand law. This sends the wrong signal to our youth and nonsmokers.

“Vape brands are clearly visible behind the counter of every dairy, petrol station, and in grocery stores. Bold, bright, colourful, and alluring brand names and imagery invite attention and interest, and are often literally affixed atop the plain white cigarette cases that sell different nicotine-delivery devices.

“As a result of this loophole in regulation, vapes and the vaping lifestyle have been widely advertised and promoted. Nielsen figures show that in the first 6 months of 2019 alone, vape marketing surged 190%. That’s more than $2 million spent in the first half of the year alone. This means vaping has achieved widespread visibility, familiarity, accessibility, and availability that cigarettes and other nicotine-delivery devices, by law, have not. And that is incredibly worrying for our youth. Vaping is positioned in the marketplace as being less risky, as well as being cool, sexy, attractive, and alluring. The Cancer Society in a report just released in September shows that 89% of secondary schools are aware of vaping by their students, and 51% report that more than a quarter of their students actively vape. As a social marketer, this is what I am most concerned about.

“The promotion, marketing, sales and use of vape products should be regulated like cigarettes are regulated in New Zealand. Vaping should no longer be marketed and sold as an appealing lifestyle choice. The public health community and the rest of us need to have this debate about what we want the future of New Zealand to look like.”

No conflict of interest.

Combined responses:

– Professor Janet Hoek, Professor of Public Health and Marketing, University of Otago, Wellington
– Professor Richard Edwards, Professor of Public Health, University of Otago Wellington

Following a number of deaths in the United States linked to vaping, what do we know about the possible cause? Should New Zealand vape users be concerned?

“The Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) have been investigating the deaths and reports of acute respiratory illness linked to vaping. The most recent CDC update advises that products containing THC appear to have played a role in the outbreak. However, the CDC also notes that: ‘the specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown at this time’ and states that ‘No single product or substance has been linked to all lung injury cases’.

“The CDC’s advice is relevant to people in New Zealand who are vaping; specifically the CDC advises people who are currently vaping not to use e-liquid that contains THC. Although the CDC recommends people to refrain from vaping, they also advise people who are vaping to quit smoking not to resume smoking. The CDC also advises adults who have never smoked not to vape, recommends young adults and women who are pregnant should not vape, and advises anyone who vapes to purchase e-liquids and vaping products from reputable suppliers (i.e., not ‘off the street’). The CDC further recommends that people do not modify or add anything not intended by the manufacturer to these products.

“People who feel unwell and have any of the symptoms listed on the CDC website should see a health professional as soon as possible (these symptoms include cough, shortness of breath or chest pain, nausea, vomiting or diarrhea, fatigue, fever, or abdominal pain. Information from the FDA is available here,

“To the best of our knowledge, no similar cases have been reported in New Zealand. People who are currently vaping should follow the CDC advice carefully and see a doctor if they experience any of the symptoms listed.

“The only people who should vape are people who are doing so to help them quit smoking or trying to switch from smoking to a less harmful alternative; vaping will likely reduce the risks they would otherwise face if they continued smoking. All people who are trying to switch from smoking to vaping should stop smoking completely (just cutting down and smoking less does not greatly reduce the health risks due to smoking) and aim to quit vaping once they are confident they would not relapse to smoking.”

How have different countries approached regulation of e-cigarettes and their liquids? Would further regulation help protect vape users against these potential risks?

“Regulation of electronic nicotine delivery systems (ENDS) and vaping products varies across countries. In the UK, these products are regulated by the Tobacco Products Directive (TPD). Among other things, the TPD restricts the size of ENDS tanks to 2ml, restricts the nicotine content of e-liquids to no more than 20mg/ml, regulates specific ingredients, and sets out labelling and warning requirements. Regulation in the US is outlined here.  Australia has more restrictive regulation.

“Within New Zealand, vaping regulation is pending and the content of the legislation has not yet been released. There are different views on how we can put in place policies that support smokers wanting to switch to vaping and ensure they can use their vapes effectively while also preventing uptake among children and young people and adults who are not smoking or vaping. Measures that may help vape users avoid the illnesses observed in the US could include:

• Developing, implementing and enforcing product safety standards and an effective adverse reaction monitoring scheme.
• Requiring licensing of ENDS retailers and allowing only people knowledgeable about ENDS and smoking cessation to sell ENDS and other vaping products.
• Making all licensed ENDS retailers R18 outlets that cannot be established near schools (i.e., to deter youth exposure and uptake).

“While people using ENDS and vaping products need to be confident the items they purchase and use are safe and fit-for-purpose, ENDS are still widely regarded as presenting fewer risks to users than smoked tobacco. The regulatory regime should reflect this difference so that measures applied to smoked tobacco are more restrictive than those applied to regulate the sale and availability of ENDS. The introduction of measures to regulate ENDS is an opportune time to remedy deficiencies in smoked tobacco regulation. Such measures should include reducing availability by introducing licensing and controls on the number and type of outlets selling smoked tobacco and to reduce the addictiveness, palatability and appeal of these products by greatly reducing nicotine content and prohibiting flavours and additives.”

Is vaping a useful tool for people trying to quit smoking? What do we know about possible harm compared to smoking?

“Some people have quit smoking by vaping but other people have difficulty making a complete transition from smoking to vaping. The National Academy of Sciences, Engineering and Medicine (NASEM) conducted a comprehensive review of ENDS and concluded: ‘Overall, there is limited evidence that e-cigarettes may be effective aids to promote smoking cessation’, which indicates the evidence base is not yet developed enough for us to have firm conclusions about vaping’s usefulness as a cessation tool.

“For people who have tried standard smoking cessation treatments and who have not been able to quit smoking using these, vaping offers an alternative approach. People need to understand that vaping will not be the same experience as smoking and they may need to persevere with vaping to satisfy their need for nicotine. For many smokers, moving from smoking to vaping is more than replacing one nicotine source with another, it can involve recreating practices of which smoking was once a part.

“The NASEM report concluded: ‘There is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes.’ The report found: ‘There is substantial evidence that except for nicotine, under typical conditions of use, exposure to potentially toxic substances from e-cigarettes is significantly lower compared with combustible tobacco cigarettes.’

“However, although the NASEM Report found that ENDS were less harmful than smoked tobacco, it is important to note that smoked tobacco is extremely harmful and ENDS are not risk-free. We do not know the long-term impact of chemicals in e-liquids and inhaled aerosols, and people who are vaping to switch from smoking should therefore aim to quit vaping as soon as they are confident they will not relapse to smoking.”

Are there any current restrictions – in New Zealand or elsewhere – about how these products can be marketed? How should marketing of these products be managed?

“The Government has announced it will introduce legislation soon but marketing is currently widespread with event sponsorship, use of social media influencers, and mass and social media advertising. This marketing reaches many young people, most of whom will not be smokers, and has much in common with the marketing tobacco companies used when tobacco advertising and promotion was still permitted.

“Awareness of ENDS products is high and trial is also high in NZ, relative to other countries. However, sustained use following trial is low. These findings suggest we do not need mass media advertising because people already know about ENDS products. Instead, we need ENDS to be sold by retailers who know the products they sell and who can provide expert advice about how to use these products and the best products to use, as well as giving cessation advice and support. That implies limiting distribution so ENDS are not sold by corner dairies, supermarkets or service stations, but by suitably trained specialist retailers or pharmacists who understand vaping products and how transitions from smoking to vaping occur.

“This approach also implies that smoked tobacco sales should be greatly restricted as smoked tobacco should be far less available than is currently the case. Smoked tobacco should not be sold in outlets selling basic foods such as bread and milk; it should only be sold in a small number of R18 outlets that sell only tobacco products.

“There has been considerable debate over the 5000+ e-liquid flavours available, many of which seem marketed to children and young people. Although it is important for smokers to find vaping more palatable than smoking, and for some vapers flavours may be an important component of the appeal of vaping, that does not mean they need an ever-expanding flavour range marketed using names and imagery that appeal to young people. Claims smokers will revert to smoking if they do not have a vast flavour array to titillate their taste buds do not appear to have a strong scientific foundation, although there are anecdotal accounts supporting this view. Much of the appeal of flavours to children and youth may be through youth-oriented descriptors, packaging and marketing. Measures to reduce this appeal while preserving the availability of a range of flavours for smokers trying to switch to vaping could involve banning text descriptors and instead describing flavours by designated code numbers and selling devices and e-liquids in plain packaging.”

Given the current state of knowledge, is it recommended that smokers use vaping to quit tobacco? What about non-smokers?

“People who smoke could use recommended and approved smoking cessation treatments, such as the many types of Nicotine Replacement Therapy (NRT), or medicines such as Zyban or Champix, which their doctor can prescribe, if appropriate. These treatments have been demonstrated to be effective and have had to undergo a rigorous approval process, and hence are likely to be the safest aids for quitting smoking.  However, not everyone is able to quit smoking using these approaches and people who have not been able to quit using existing treatments may wish to try ENDS; however, they should buy their device and e-liquid from a specialist outlet. They should also aim to quit using ENDS as soon as they feel they would not relapse to smoking.

“Non-smokers should neither smoke nor vape; doing either will increase the risk of harm they face. People who are addicted to nicotine typically dislike the hold it has over them and resent the loss of control they experience. For them, the struggle to rid themselves of nicotine is not worth the short-term sensations that led to their addiction.”

Conflict of interest statement: We co-direct ASPIRE, a University of Otago Research Centre, and have undertaken several studies designed to inform smokefree policies. We have received funding from the Health Research Council of New Zealand, the Royal Society Marsden Fund, the New Zealand Cancer Society, the New Zealand Ministry of Health, and other NGOs. We have never received funding from the tobacco, vaping or pharmaceutical industries (or related commercial interests), nor from the Foundation for a Smokefree World.