The PRAXIS Nexus The PRAXIS Nexus

E-cigs: How Did We Get Here AGAIN?

Posted on July 18, 2019   |   
18 Comments   |   
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Guest blog by Mike Hess, RRT, RPFT

One of my all-time favorite TV shows is Battlestar Galactica. While I grew up with the campy, cheesy original with Lorne Greene shepherding the “rag-tag fugitive fleet” to a new home among the stars, I actually prefer the more recent 2005 reboot. This version took a much more grounded, realistic approach to storytelling and moral discussion. One of the recurring motifs of the show is the phrase, “This has all happened before, and it will happen again,” and ideas like resurrection, learning from history, and breaking cycles.

Unfortunately, this motif seems to have become all too real for anyone involved in the lung health community. I was recently at a meeting of one of our local Better Breathers groups to discuss the upcoming launch of a new Harmonicas for Health program, and the group facilitator had brought some prints of old cigarette ads. The messages on these ads ranged from the clinical (“20,679 Physicians Say “Luckies are less irritating!”) to the risqué (“Blow in her face, and she’ll follow you anywhere”), but a common theme is that certain cigarettes are awesome. They’re what the cool kids like Lucille Ball and Bob Hope are doing, and some of them can actually even be good for you. After all, if the typical smoker inhales 200 times per day, that’s “200 good reasons you’re better off smoking Philip Morris,” right? They’re proven mild! (**NOTE: Most of these ads are available at https://gizmodo.com/14-absurd-ads-from-before-we-knew-cigarettes-could-kill-1499396560 for citation and/or pictures, Hope/Ball ads are at http://exhibits.library.yale.edu/exhibits/show/sellingsmoke/celebrities**)

We know better these days, of course. We know that no cigarettes are healthy, no cigarettes work to improve asthma, bronchospasm, or anything else, and it wasn’t cigarettes that won World War II. We know that these statements are absurd and ridiculous. But we also know we’re seeing the same kinds of imagery and arguments being used right now to support electronic nicotine delivery systems, or ENDS. These devices, more commonly known as vapes or e-cigarettes, are becoming nearly ubiquitous in modern society, much like smoking once was. And, again as in the case of their combustible ancestors, these devices are being sold as an indispensable accessory for an aspirational lifestyle.

The idea of an electronic cigarette first came about in the 1960s. A gentleman by the name of Herbert Gilbert, a two-pack-a-day smoker, decided that combustion was likely the biggest problem with smoking. After all, as he described in an interview, a person could eat certain leaves or barks (like cinnamon) without harm, but as soon as those things were burned, they could cause major damage to the respiratory system (https://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.html). A few iterations later, an electronic inhalation device was born, promising to not only deliver society from the risks of burning tobacco leaves, but (ironically) to provide other remedies “under direction of a physician” (https://patents.google.com/patent/US3200819).

Despite Mr. Gilbert’s best efforts, no company seemed interested in his new “Smokeless.” The technology essentially lay fallow for nearly four decades, until a Chinese pharmacist by the name of Hon Lik (coincidentally, another smoker) submitted a new patent application for similar device that used ultrasonic vibration to vaporize liquid. No longer ahead of its time (or fighting against as much traditional tobacco advertising), Mr. Hon’s Ruyan device and its many imitators quickly spread across the globe. Whether atomizing via sound waves or more conventional heating coils, this new method of nicotine intake seemed cleaner, safer, and more accessible than old-school tobacco. In addition, because these devices had potential medical applications, they didn’t fall under traditional tobacco regulations (at least, in the United States) and represented a whole new world for tobacco companies to explore and recruit.

Regulation has (slowly) been catching up to the realities surrounding ENDS devices, but in many aspects the damage has already been significant. The widespread availability or (and lack of short-term effects related to) these devices has contributed to a belief that the vapor generated is far safer than any ‘smoke’ from traditional combustible cigarettes. You don’t have to take my word for it; in December 2018, the Kalamazoo County Substance Abuse Task Force conducted focus groups with middle- and high-school students in our area, asking about their perceptions about e-cigarettes. Many of the students who had used these devices felt they were a “healthier alternative to regular cigarettes,” as well as “fun,” “cool,” and made them “look like an adult.” These perceptions have led to a 10% increase in the reported use of e-cigs by high schoolers in the area, with nearly 1 in 3 reporting they had sampled a device within the last 30 days (2018 Kalamazoo Community Report, https://www.prevention-works.org/uploads/4/7/2/8/47288851/prevention-works-community-report-2018.pdf).

Where did these perceptions come from? It seems, in large part, essentially the same place they came from before: advertising. The gap in regulation has allowed the industry to apply the lessons of the early 20th century to modern technology. Instead of Lucy and Desi talking about smoothness, now we see Instagram influencers promoting “cloud competitions,” challenging their audiences to create the largest possible exhaled vapor plume. Current idols and role models are promoting vaping as a safe, healthy activity. Current TV ads even describe certain e-cigarette brands as having “the perfect puff,” and giving smokers more “control.” Sound familiar?

All of this has happened before, but it does not necessarily have to happen again. Even if we clinicians allow for the possibility ENDS devices may end up being a viable tool for tobacco cessation, it seems clear that current tobacco regulations (including advertising restrictions) should also apply to these gadgets. We can learn from the lessons of the early 20th century and reduce the kinds of exposures that led to the COPD epidemic we have on our hands today. We don’t entirely know the long-term effects of vapor exposure, but it seems reasonable to err on the side of health. Promotion of proven, evidence-based strategies for tobacco cessation, as well as reminding our younger population that vapor is not demonstrably any more pure, safe, or clean than combustion by-products, will help prevent an unnecessary repeat of the anti-tobacco efforts of the last 30-odd years, and allow us to devote our resources to more effective management strategies and research efforts. So say we all!

18 Comments



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  • Off topic but enjoyed the BSG reference Mike. You have inspired me to binge watch some BSG while avoiding the heat this weekend.
    Reply
  • My father was a mailman in the 1940s. They had few days of delivering cartons of cigarettes to all the doctors in town. A few months later, ads appeared saying, "More doctors smoke Camels than any other cigarette." You don't suppose the surveys were done a couple of weeks after the delivery of free cigarettes, do you?
    Reply
  • Hi Mike
    I cannot agree that vaping is in any way as dangerous or damaging than lighting a bonfire in your mouth and inhaling the smoke just to gain access to the nicotine ... which is what cigarettes are for..... whereas inhaling vaporised glycerine containing pure nicotine must be a far safer way of attaining the nicotine hit. As nicotine is not a banned substance I must support vaping as the new way of "pretend smoking" without lighting a cigarette and the cloud of fake smoke [harmless vapor containing nicotine] merely makes it look more like smoking without the dangers.
    https://healthfully.com/273274-smoking-breathing-rate.html
    The Effects in the Lungs from the very first puff on a cigarette is the smoke and all its chemicals begin to damage your lungs. Immediately it aggravates the cilia, which keep your lungs clean. Eventually these cilia are bogged down in tar, and airway passages become narrow. The lining of the entire respiratory system becomes thickened and inflamed, further narrowing the airway. Smoke also deteriorates elastin in the lungs, which allows this vital organ to expand and retract during breathing, according to Smoking-cessation.org.
    As much as you put the blame on advertising, which I totally agree was the problem with cigarettes being popularised over time, I believe by adverting vaping or ENDS is saving many youngsters from even thinking of smoking cigarettes which are becoming uncool with the younger generation and thereby protecting them from the consequences such as COPD.
    just my thoughts as I believe vaping is at least 90 per cent safer than smoking tobacco if not more
    Thanks for the bringing up the topic Mike...… best regards ….striker

    Reply
    • You could well be right. The problem is, you could also well be wrong. We honestly don't know what the long-term effects of inhaling even things like glycerine are going to be. Your airways aren't really designed to cope with that sort of thing, and preliminary studies are suggesting it can cause inflammation and reaction much like asthma. Over time, that builds to chronic inflammation, which is something commonly seen in COPD.

      Seeing as we don't know what the risks actually are, it's not something I can in good faith recommend to anyone. At best, e-cigs *could* (triple emphasize COULD, because the jury's still out here, too) be a last-resort tobacco cessation tool. But otherwise, there's really no space for them; certainly not to the degree the ads would have us believe.

      Thanks for continuing the discussion!
      Reply
    • The Lungs were never designed to inhale anything but the cleanest air possible and that has been proven on many levels for decades. We know that inhaling cigarette smoke causes Significant lung problems and cancers. We know that over exposure to Dusts, Wood Fibers, paints and solvents, fuel fumes, and others such as asbestos, etc cause lung damage and disease. E-cigarettes have been found to contain diacetyl a chemical linked to serious lung disease, also metals such as nickel, tin and lead. Some of these cartridges are manufactured in other countries with less stringent regulations. Nicotine is also known in adolescence to cause addiction and harm to the developing brain.
      Inhaling chemicals may not have an immediate response, much like the bodies responses to certain surgical procedures or organ transplants. The body can, may and will show inflammatory responses later down the road or even full rejection. The lungs are nothing to mess around with. The question will always remain, why do people even want to take these risks? especially when the science is not clear as to what can happen!
      Reply
  • Thanks for posting this. I think this is something that should be out there on an ongoing
    The ads for ENDs are very similar to the old cigarette ads; doctors, Santa Claus, sex appeal, ruggedness....
    Fortunately, there are also some pretty great anti-vaping ads out there as well.
    Reply
  • NJ like many states is tightening up the laws on vaping. Advertising is banned on NJ public transportation, that is a small step in the right direction.

    The sale of any electronic device to a person under the age of 21 is illegal and local ordinances are starting to ban vaping in some public places.
    Reply
    • I'm hopeful this is a trend that grows! I'm hopeful we can do more than just laws, though; I knew enough underage smokers in my day to know that where there's a will, there's a way. Some local surveys here in Michigan are indicating e-cigs are following that course as well. Public health advocates have to do a better job at getting the message out in an accessible, relatable way.
      Reply
  • My niece recently caught her 14 year old son with a JUUL, it fell out of his pocket. After failing to convince her it was for his Xbox controller, they had the talk. He just wanted to be cool like the older kids. Fortunately he is into sports so when he heard increased risk of heart attack, increased risk of heart disease, asthma like symptoms, and everything else he got the message. Basketball and maintaining his “sports” health won out but not all kids have that other “thing” that is important to them.

    https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html
    Reply
  • One of my customers who is also a teacher of 5th graders at the school right down the street from my store, has cameras throughout the school due to protection from gun violence and he said you see them hitting on their jewels or USB sized vapes, 5th graders!
    Reply
  • Great article! Thanks Mike
    Reply
  • Nice post and great discussion on this controversial topic; I worry that the FDA is so far "behind the eight ball" on this issue when it comes to variability in the manufacturing of these devices; as well as, the liquid ingredient mixtures that are being vaped that research conclusions will be difficult... Has anyone seen this online store...it's crazy! https://www.myvaporstore.com/

    Also, this was nice article recently in the Nature journal: https://www.nature.com/articles/d41586-019-01785-4
    Reply

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