16 November 2017:
Samir Soneji had no idea what he was getting into when he agreed to talk about the potential risks of vaping at the first US E-Cigarette Summit in Washington, DC this past May. His first clue was the booing.
As a professor at the Dartmouth Institute for Health Policy and Clinical Practice, Soneji studies how gaps in tobacco regulation affect health. Two years before the conference, he’d reported in JAMA Pediatrics that young people who smoke hookah or use “snus,” a form of moist smokeless tobacco, are twice as likely to try cigarettes as kids who don’t. He suspected that e-cigarettes, with kid-friendly flavors like “Cinnamon Roll” and “Peanut Butter Cup,” carried a similar risk. And that’s exactly what he and several colleagues discovered in a recent review of studies that tested that possibility.
Evidence that tobacco companies targeted teens and nonsmokers with candy- and fruit-flavored cigarettes prompted the Food and Drug Administration to ban them in 2009 under the Family Smoking Prevention and Tobacco Control Act. But those restrictions do not apply to e-cigarettes and hookahs, even though the FDA extended its authority in August 2016 to include all forms of tobacco.
Soneji figured that people who came to a conference about the science and regulation of e-cigarettes actually wanted to hear the latest science, whatever the data showed. So he told the audience what he and others had found: youth who vaped were more likely to start smoking cigarettes than those who didn’t. What’s more, kids who made the leap from e-cigs to cigarettes probably wouldn’t otherwise have started smoking, he explained, because they didn’t suffer from anxiety or depression or use alcohol or drugs — risk factors associated with youth smoking. He also shared evidence that “fun” candy-flavored e-cigarettes attract kids, just as flavored cigarettes did, and that, because labels often misrepresent nicotine levels in the devices, even kids who think they’re vaping only flavors could be inhaling nicotine.
The booing was not the only sign to Soneji that this was not a typical scientific conference. He later joined a Q&A panel before the morning break. There, a Johns Hopkins researcher who said he consults for pharmaceutical companies and Reynolds American — which makes VUSE, the top-selling e-cig brand in the US — asked the panel when public health officials were going to communicate positive messages about how vaping reduces harm, like they do about using clean needles and condoms to stem the spread of disease. Soneji said it would be premature and dangerous to recommend e-cigarettes to help smokers quit, given the lack of rigorous scientific evidence to support it. Minutes later, the head of an anti-smoking organization rose from the audience to dismiss his call for more evidence as “rubbish.” The crowd laughed and cheered.
Many people in the audience, Soneji would discover, had an emotional or financial interest in vaping — and they didn’t pay up to $1,100 a ticket to hear anyone question the benefits of e-cigarettes. “I didn’t realize just how many people would be from the industry, and whose job and livelihood is [tied] to e-cigarettes,” he says. “Hearing about the harms of vaping came across as threatening to their existence.”
Many people Soneji spoke to after his talk argued that e-cigarettes save lives. They told him it’s the tar in cigarette smoke that causes lung cancer, and since e-cigarettes don’t have tar, there’s nothing to worry about. An ex-smoker-turned-vaper who had opened a vape shop to help others quit smoking told Soneji that his products were safer because they don’t produce cancer-causing tar. While that’s true, Soneji says, “he was very dismissive of any cardiovascular effects around vaping and nicotine, and around the chemical by-products of heating the e-juice.”
Public health campaigns have so successfully tied smoking to lung cancer that people often don’t realize more smokers die of cardiovascular and metabolic diseases than of lung cancer. Soneji tried to tell the shop owner, and many others at the summit, that smoking significantly increases the risk of cardiovascular disease and that recent studies suggest e-cigarettes also increase heart attack risk. But they didn’t listen to him. They didn’t understand how anyone could question the value of a product they believe helps people quit one of the world’s deadliest habits.
Online forums are filled with stories from ex-smokers who saw striking health improvements after switching to vaping. “I no longer wake up coughing and hacking up gunk for the first two hours of my day. I’m no longer getting winded doing the smallest things,” reported a member of the E-Cigarette Forum, which calls itself “the voice of vaping since 2007.”
