Almost 5 million Canadians over the age of 12 smoke, in a country of 37.59 million. 45,000 will die of a smoking related disease every year. Health Canada’s goal to reduce smoking from almost 16% down to 5% of the population by 2035 is very ambitious given the tight timeline and the continued uptake of smoking by young people. That’s why the introduction of nicotine vaping has been so exciting. With a switch rate almost double that of other nicotine replacement therapies (NRTs), vaping is unquestionably a game changer.
Much of vaping’s success is owing to the designers of the technology. Unlike traditional NRTs that have been thought up in pharmaceutical laboratories and by tobacco firms, vaping was and continues to be developed by former smokers for smokers. They are uniquely positioned to understand both the appeal of smoking and what makes it so difficult to quit and the necessary attributes of an effective replacement therapy.
The Technology and How It Works
Nicotine vaping delivers on several fronts: critically, it is first and foremost a nicotine delivery system. While a certain amount of willpower is required to fully switch from smoking to vaping (as is required to break any habit), the e-cigarette continues to deliver nicotine to the end-user. Nicotine amounts vary from an amount similar to what is available in a traditional cigarette down to 3 mg/ml. Many transition at higher nicotine levels to avoid the worst of withdrawal symptoms and step down naturally over time. Some ex-smokers prefer to find their ideal nicotine level and stay there, avoiding the deadly effects of smoking while preserving their enjoyment of nicotine.
An important aspect of vaping is the act of vaporizing itself. With the push of a button, the coil inside of the device heats up and heats the nicotine e-liquid, transforming the liquid to vapour. This simulates the mouth feel of inhaling smoke without the combustion and the dangerous effects of inhaling actual smoke and provides the end-user with a satisfying exhale. It also maintains the hand-to-mouth habit to which the end-user is accustomed.
Perhaps most importantly though is that e-liquids not only come in a wide range of nicotine levels but an even wider range of flavours. This is critical to so many smokers who have been unable or unwilling to quit smoking by other methods. While vaping is considerably more satisfying than other NRTs, it is not quite as satisfying as smoking- particularly for a years long or heavy smoker. Smaller, pod devices that deliver higher nicotine levels faster in the form of nicotine salts come close, though for many the amount of vapour is not fully satisfying. But flavours change the game. Flavour is the one area where vaping beats cigarettes by a generous mile.
Even the most dedicated smokers (and there are a great many committed smokers, it’s patronizing to assume that all smokers want desperately to quit) will acknowledge that the smell and taste (and after-taste) of cigarettes leaves something to be desired. And this is where ex-smokers in the vaping industry really went to work, developing an ever-expanding range of flavours to suit every palate. There are flavours ranging from traditional desserts like custards and cheesecakes to confectionary to all manner of fruit combinations, in addition to more basic tobacco-like offerings and simple mint and menthol.
There is a popular refrain from vaping advocates, most particularly in the United States, that “flavours saved my life.” It doesn’t translate well outside of the vaping community but what is meant is that flavours were a determining factor in being able to fully make the switch from combustible cigarettes to nicotine vaping. For all of the other attributes of vaping, flavour is often a deciding factor. Vaping tastes and smells considerably better than the most enjoyable cigarette a smoker has ever smoked. And a person doesn’t have to choose just one flavour and stick with it: they can choose to switch between multiple flavours during the day (much the way one eats and drinks a variety of food and beverages).
Add to this the wide range of devices that allow a user to be more or less involved with their habit, which can be helpful for people dealing with addiction issues outside of strictly smoking as well as mental health issues. It is not uncommon, for instance, to hear that end-users enjoy the practice of building intricate coils for their devices or even just the practice of breaking down and cleaning their devices.
Diffusion of Innovation: How and Why It Works
We are only still just at the beginning of this exciting advent. Though the technology has been around for some time now, vaping only started to enter the mainstream around 2006. When you think about previous game-changing technologies, from refrigerators to televisions to computers, popular uptake is generally limited to early adopters in the immediate years. Those who are more inclined to try something new will (and that is more limited than many of us believe) while the majority wait to see where a product is going. And during this time, great advances are normally made in the technology and/or price point, etcetera. We have seen rapid advancements in the development of vaping technology but it would be a mistake to assume that it has hit its peak yet. The potential of vaping technology to convert more smokers than ever before is incredible.
According to Everett Roger’s theory of diffusion of innovation, there are five stages involved in the diffusion of any new technology or idea. There is the knowledge stage during which the public is aware, in a general sense, that the technology/idea exists. The persuasion stage sees the public increasingly intrigued and actively seeking to learn more. The decision stage is just that: a decision is made whether to accept the new technology or to reject it. The public weighs the cost of switching to the new technology/idea and weighs the advantages and disadvantages of using it. (Note that this stage is highly individualistic, with innovators and early adopters by nature being more willing to entertain new ideas and weighting things differently from early majority and late majority- i.e. mainstream– users.) Should the decision be made to accept it, there is next the implementation phase during which the end-user will start to use the technology or idea. The final stage is confirmation, having used the technology or idea the decision is made to continue with it- it has proven its value and/or received enough confirmation by the population that it is accepted. During this time, a technology can fail through no specific fault of its own but due to a weakness against competing interests or simple lack of awareness. (Governments can play a role here, helping to promote a technology that they feel is in the public interest as the U.K. government and public health officials have with regards to vaping, increasing the likelihood of success.)
Although, as mentioned, vaping technology is still in relatively early stages both innovators and early adopters have largely accepted vaping, hence its higher success rate than other NRTs and spread around the globe. The general public looked poised to move through the persuasion stage. With so many smokers in the world and our understanding of the extreme dangers of smoking the public is inclined to entertain options with the potential to save lives, whether their own or those of loved ones. It is here, however, that a hitch occurred.
As is so often the case, competing interests came into play, namely those of pharmaceutical companies whose profits are tied to the NRTs that they produce and the numerous attempts at quitting that a smoker will make over their lifetimes. The “if at first you don’t succeed” mantra is pulled out time and again to convince smokers that just because a patch/gum/mist/lozenge didn’t work the last time, doesn’t mean that it (or some combination) won’t this time. There’s a good deal of profit in producing something that holds the promise of being effective but generally requires repeated attempts.
The argument could be made that none of these NRTs are so much effective as that by the time a person tries again and does manage to succeed, it is their increased willpower and not the product that is due the majority of credit. But the desire to see people quit smoking is so strong that these early NRTs have largely been accepted even with a rather dismal success rate. (And far be it from me to dismiss any product with the potential to help smokers transition off cigarettes.) This new technology, vaping, does have the potential to displace traditional NRTs though and that is a considerable threat to financial interests. One reason, in addition to higher conversion rates, is that people with no real desire to quit smoking have quit smoking through vaping- simply by trying it on a lark- something that no other NRT can claim.
The other pushback against vaping technology has come from what we’ll call the anti-groups. These groups were largely anti-smoking prior to the advent of vaping. They, rightly, recognized smoking as a huge threat to the health and well-being of our population. They have actively campaigned over the years to educate the public (sometimes through the straightforward presentation of facts, sometimes through embellishment and fear campaigns) and put pressure on government and public bodies to act accordingly. While their campaign can be criticized for its tactics (stigmatizing smokers to an extent that it has become acceptable to treat people who smoke as undesirable degenerates, for one, exaggerating the danger of smokers to the general public, for another) it has been largely successful by its own objectives.
There are still a considerable number of smokers worldwide but demonstrably less than at the start of their campaign (not that they can be credited for that in full, but they played a role). Smoking has largely lost its appeal in the mainstream and is limited to more vulnerable communities. And, whether we like to acknowledge it or not, we tend as a whole to be less concerned with vulnerable communities.
The anti-groups have recently shifted their focus from the remaining 1.1 billion smokers worldwide and combustible cigarettes to nicotine more generally. Or, more specifically, not the nicotine contained in patches/gums/lozenges/etcetera but the nicotine delivered via electronic cigarette. It should be noted that, while potentially addictive or dependence forming, nicotine has never been shown to be any more dangerous than, say, caffeine- in fact sharing similar effects on the body. That is a big part of why NRTs achieved public acceptance. It is widely known that nicotine is far less harmful than broadly accepted drugs, alcohol for one example.
But the framing of the anti-groups (supported in large part by pharmaceutical companies, government funding, and wealthy benefactors) has been so successful over a remarkably short period of time that this new terror of nicotine has reached moral panic levels and repeated refrains to “think of the children.” It is true that young people, the largest cohort of risk-takers, have taken up vaping in statistically significant numbers. Taking Canada, for instance, 20% of young people have tried vaping- whether of nicotine containing e-liquids or non-nicotine containing e-liquids. Of that 20% though, 58% had previously tried smoking and of the 42% who had not previously smoked it might be said that they were making a less risky choice, if still undesirable. (Wouldn’t it be lovely if we could keep all children, or at least those from certain socioeconomic backgrounds, as pure as the driven snow?)
Given, however, that the Canadian government estimates that 21% of young people are assessed at being at high risk of substance abuse it is surprising that the 20% who have tried vaping have risen to the level of concern that has been generated. The 44% who drink, for example, have received little to no attention from the public or anti-groups. But as a group, humans are inherently bad at evaluating risk. It would seem, at least in this case, that teenagers are evaluating risk better than the adults worried about them.
This panic reached a peak with the recent black market THC related lung injuries, when anti-groups, media, and some public health bodies and officials took the opportunity to spread fear around nicotine vaping even further, at a heightened pitch befitting the reefer madness days of years past. Even the CDC got on board (in contrast to the FDA’s more cautious pronouncements) warning the public about e-cigarette use. Health Canada took the unusual step of being remarkably quiet and overly cautious, speaking hardly at all to the issue publicly while continuing to issue warnings to the nicotine vaping industry about youth uptake in response to public backlash.
To be clear- these incidents were real and required serious action. Advisories should have been issued to prevent unnecessary injuries and deaths. And some journalists, though remarkably few and not generally from the mainstream, did take it upon themselves to learn as much as they could about the incidences and warn people in real time- about vaping THC, especially obtained through informal/illicit sources. It was clear from early on, to anyone with a modicum of common sense, that the injuries sustained could not be linked to nicotine vaping, that the acute onset and geographically localized nature of the injuries and deaths indicated that something entirely different was at play. But this didn’t stop the CDC from changing the original name of the injuries from VAPI (Vaping Associated Pulmonary Injury) to EVALI (E-cigarette Vaping Associated Lung Injury) and advising the public against nicotine vaping.
The CDC has since concluded (months behind Leafly, the e-cigarette industry, independent journalists, and many medical experts) that the injuries and deaths are linked to the use of black market THC products, and more specifically to vitamin E acetate used as a cutting agent in these products. But they have not reverted to the original, more fitting, name of VAPI to describe the injuries nor have they been as vocal as they need to be in order to correct the record and warn people of the very real risks that still exist. Two more deaths were recently recorded. This is outrageously reckless with the public health, particularly so with vulnerable communities.
This will no doubt be recorded in history as one of the worst public health failures of the early part of this century and hopefully we don’t have many more to rival it. Not only were more people put at risk of dying from bad THC cartridges during this time but many- under what they felt was the advisement of public health authorities- returned to smoking, Canadian provincial governments and American state level governments moved rapidly to restrict the availability of nicotine vaping products, and anti-groups took the opportunity to increase their lobbying efforts- indeed, getting a seat at the table with the President of the United States.
Legitimate businesses have been shuttered, those remaining are permanently on the backfoot and in a state of distress, many smokers have been convinced to stick with their habit, and many in the general public have been convinced to support anti-nicotine vaping measures, including full bans. What was not so long ago a breakthrough technology with the potential to contribute in a serious way to the disruption of smoking rates now faces an uncertain future.
The CDC’s concession that e-cigarettes were not, after all, to blame has not slowed the roll of anti-groups and anti-nicotine vaping proponents though. Case in point, at the Ottawa Model Smoking Cessation keynote speaker Stanton Glantz, whose recent work has largely been discredited, delivered his address with such notable bullet points as, “combustion is not as important as we thought,” and “dual use more dangerous than just smoking” and “pollute nonsmokers air” and “rapid youth uptake- promoting progression to cigarettes.” And while anyone might find any of these points laughable, having no basis in fact, attendees of the Johnson and Johnson sponsored event tweeted his powerpoint presentation with nary a twinge of skepticism. Another popular point from Glantz was that for every smoker who quit smoking by vaping, 80 kids started. This is basic math that could be easily questioned, and yet within the conference there seemed to be no questions at all.
UBC professor Dr. Mark Tyndall, who specializes in public health, said of Glantz, “This professor, in my view, is very radical. At the end of the day, there are millions of people vaping. Clearly this is a much safer alternative (to smoking). Now people are starting to question whether they should vape. He can do a lot of damage.” He can and he has but he’s far from alone in his efforts or incendiary and baseless statements. In fact, the World Health Organization (WHO) recently published a list of concerns with e-cigarettes including the now debunked link to deaths and lung injuries in the United States even after the correction had been made.
The WHO went on to add to its list of concern with e-cigarettes such standout claims as e-cigarettes may be more dangerous than combustible cigarettes and that second-hand exposure to e-cigarette aerosol is a danger to the public because it can “contain toxic substances, including glycol which is used to make antifreeze.” Propylene glycol used in nicotine e-liquids is also found in foods such as cakes and icings, in natural flavourings such as vanilla and almond extracts, in medicines, in cosmetics, and a wide variety of consumer products. It is also used in antifreeze to replace ethylene glycol that used to be used and is toxic to humans and animals if consumed. Take from this what you will but we are left with two options: either the World Health Organization is too stupid to know the difference or they are intentionally misleading the public.
Michael Bloomberg, the presidential candidate who has never met a habit he doesn’t want to reform, has claimed that nicotine vaping can lower your child’s IQ by 10-15 points. No basis for the statement, not even an attempt to defend it- just a radical statement meant to strike fear in the hearts of parents. The ironic thing is that while vape advocates and industry members are continuously told that the evidence, the research, the studies, and the substantial anecdotal evidence that they present is “not enough,” the anti- side (and I would include government bodies here) is not required to substantiate their claims.
Ethan Nadelmann who founded the Drug Policy Alliance in the United States and whose TED talk “Why we need to end the war on drugs” has reached almost two million viewers, has expressed concerns that the antagonism towards vaping might signal the next drug war. It certainly seems that way, with anti-vaping proponents needing no more evidence than “we don’t know the long term effects” which is true about many consumer products on the market today, more so than with nicotine vaping which has been available in North America and in Europe since 2006.
But this isn’t unusual in the field of harm reduction. Not so long ago we worried that providing clean needles to drug users would encourage more drug use when in fact it did not and helped to slow the spread of H.I.V.. We were also convinced for a time that promoting the use of condoms would encourage promiscuity and premarital sex when the results were fewer unwanted pregnancies and sexually transmitted diseases. Sex education was going to turn our children into nymphomaniacal degenerates and yet again has only helped to decrease teen pregnancy and the spread of STDs. The debate is ongoing whether safe consumption sites encourage drug use, though they have been shown to reduce drug-induced fatalities. Reducing access to abortion does not decrease the number of abortions, it just makes them less safe. And this is not limited to harm reduction either, as a society we don’t much like change once we have accepted a premise as true, however outlandish.
Where things go from here
All this to say that if we return to the theory of diffusion of innovation, the nicotine vaping industry is not only on the back foot but poised to be severely curtailed if not altogether destroyed. It has largely stalled at the persuasion stage while the public struggles to make sense of conflicting reports and moral panic. And this is a shame for what promised to be such an exciting disruptive technology with the potential to do so much good. Years from now we will no doubt look back on this as a shameful period, so wrong-headed as to be criminal. Nicotine vaping will survive, I believe, but whether it remains in the hands of the innovators or whether it is taken over by the pharmaceutical industry (with its dismal track record but very deep pockets and ability to navigate government) remains to be seen. The success of vaping to displace smoking largely depends on that question.
The Canadian Chief Medical Officers recently released a statement that may indicate the direction things are headed. The statement opens with, “over 45,000 people dying from smoking-related causes each year” and very quickly moves to “nicotine addiction” more generally. This indicates a misunderstanding of why people are dying, even though it is specified that the deaths are “smoking-related” and not “nicotine-related.” But this shift in focus also allows the promotion a new narrative: that nicotine is the risk factor and therefore use must be discouraged except in cases where limited use of an approved NRT is required to displace smoking.
To the nonsmoker or non-nicotine user that may seem an inconsequential shift. To a dedicated or recreational nicotine user, a category many vapers fall into, it is most certainly of consequence. For one, it renders vaping almost ineffective as a cessation tool. While an acceptable timeline for weaning off nicotine has not been specified by the Medical Officers, it is taken that there is one. There is a recommendation to, “Research the effectiveness of vaping products in supporting smokers to end or reduce their use of all nicotine-containing products.” It’s worth pausing to read that again. The goal then is not to support smokers to quit smoking (which vaping does, thereby preventing smoking-related disease and death) but to “end or reduce their use of all nicotine-containing products.” That is a serious shift in objective.
While the New England Journal of Medicine concludes from their research study that, “E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy” critics have subsequently pointed out that 40% of the successful vaping cohort was still using nicotine e-cigarettes one year later. This doesn’t take away from the fact that e-cigarettes were almost doubly effective that of NRTs in helping smokers to quit smoking but it does move the goal post from quitting smoking to quitting nicotine.We cannot afford to allow the distinction to go unnoted. It is absolutely critical to insist that proponents make the case for quitting nicotine outside of a moral argument or hypothetical.
The assumption that every smoker wants to quit is patronizing. It is assumed that because smoking is a dangerous activity with the potential to kill its user, every smoker wants to quit. And smokers who have quit largely agree- but they are a self selecting group. Many people who smoke (and I would have included myself in this group several years ago) do not want to quit. All of the warnings, stigma, health effects are ineffective with this group. (So too with people who use nicotine under the advice of their physician, people with schizophrenia for one example.) But even more patronizing is the shift in focus from deterring adults from smoking to preventing their use (and more specifically enjoyment) of nicotine. This moral posturing serves no real purpose.
Unfortunately the false premise that nicotine in and of itself represents a danger is one that has been accepted by and large by society. Part of this misconception is due to the wrongly held belief that nicotine causes cancer (it does not). Another is that nicotine is addictive or dependence forming. While true that nicotine can be dependence forming, that in itself should be of no more concern than the fact that caffeine is dependence forming, or that alcohol is (arguably, alcohol should be of greater concern, with considerable health effects linked to its overuse or abuse). The fact is that we don’t normally concern ourselves with other people’s habits, or at the very least habits don’t rise to the level of public health concern- and it shouldn’t here.
Regrettably, even members of the vaping industry have conceded this false premise by suggesting that persons with no preexisting relationship with tobacco shouldn’t vape. There’s no basis for that statement. We don’t ask adults whether they have an existing relationship with coffee, or with wine, or with marijuana, prior to allowing their purchase to go through. There is no reason to treat nicotine any differently. I expect the concession was made with the expectation that would afford some protection to the industry (“we’re looking out for the public health”) but it was a silly one with foretellable consequences.
The other argument against nicotine vaping is that it may lead to smoking. Again, there is no basis for this assertion. Almost anything is possible if that’s how we choose to evaluate it but it is hoped that we craft legislation on evidence, not fortune telling. The fact is that smoking rates continue to go down or remain stagnate in jurisdictions where vaping is available. All measurable evidence indicates that vaping does not lead to smoking.
The government’s intention to severely curtail smoking rates by 2035 will require every innovation possible to be available. Instead, the government is poised to regulate out of existence (certainly out of favour) perhaps the most disruptive technology in its field. Designers and manufacturers currently dedicate far more time and energy reacting to proposed restrictions than they do to further innovating, to planning and experimenting with designs. We worry about the effect of a climate of uncertainty for every other industry but this one. It is remarkably short-sighted.
Yes, we must discourage youth uptake and enforce current laws (reversing others, enacted in knee-jerk fashion), but we must also assess the results rationally. And we must not, in the midst of what might rightly be considered a moral panic, lose sight of the 45,000 Canadians and the 8 million people worldwide who die each year of a tobacco-related disease. To quote Adam Thierer, “No matter how well intentioned, sometimes hyper-precautionary rules can be deadly. By defaulting public policies to super-cautious mode and curtailing important innovations, laws and regulations can actually make the world less safe.” That is the trajectory we are on, buoyed by an anti-vaping collective that would see smokers either quit or die. The course must be corrected and soon.