Vaping acts as a replacement nicotine source which may precipitate a new public health crisis, writes Hannah Harn
Cigarette smoking, which causes nearly 6,000 deaths in Ireland each year, is on the decline. The annual Healthy Ireland Survey found that the prevalence of smoking dropped from 23% in 2015 to 20% in 2018, and nearly 44% of respondents who smoked in the last 12 months had attempted quitting. More and more people are seeking alternatives to smoking or quitting altogether.
The shift, however, is less of a decreased desire to smoke than it is a desire to smoke differently. One of the largest factors pulling people away from traditional cigarettes is the rise in e-cigarettes, or vapes. Rather than relying on burning tobacco, e-cigarettes use a heated fluid in a cartridge that can be refilled by users.
Anyone who has waited on a bus beside anyone vaping can’t fail to notice it comes in a variety of fragrances.
A global study by Ernst and Young in 2016 found the most popular reason for using e-cigarettes was that it is “less harmful than regular cigarettes”, and Euromonitor International found Ireland to have the third largest population of e-cigarette users on the planet, behind Japan and Britain.
While one of the main reasons given for using e-cigarettes is the decreased health risk from traditional cigarettes, e-cigarettes act as a replacement nicotine source for many of their users, which may well precipitate a new public health problem.
The Irish Health Information Authority published a study arguing that the most cost-effective form of NRT (nicotine replacement therapy) in Ireland is using e-cigarettes in combination with certain prescription medicines.
But, most medical groups still feel that the long-term effects of e-cigarettes are unclear, leaving people in the dark about whether they are truly the right option to replace nicotine over, for example, nicotine patches or other similar products.
Dr Patrick Doorley, Chairperson of ASH Ireland, Council of the Irish Heart Foundation, tends to see the information around e-cigarettes and their risks and benefits to be less than helpful.
“There is a growing consensus that they help people to quit, and they are almost certainly safer than tobacco,” Dr Doorley told The Irish Catholic, “and in fairness, I suppose, they are almost certainly safer than tobacco. But then, tobacco is the most lethal consumer market product ever.”
“They’re cheaper, and they’re an aid to quitting traditional cigarettes,” Dr Doorley said. “They are an option for people who have tried other methods and been unable to quit, so they are an option, but in our view, and we feel strongly about this, they should not be the go-to option.”
“Some people argue that it helps them to cut down on cigarettes,” he said, “but the problem there is that four cigarettes still does a lot of damage to hearts and lungs.”
Dr Doorley also pointed out that the main source of division among health authorities about e-cigarettes is the conflicting approaches used by researchers around the world. While it is necessary to have many experts studying the issue, this multitude of voices appears to make discord rather than progress.
“American academics tend to adopt a moralistic approach [to their e-cigarette research], but we really should be taking a scientific approach,” he said. “The public should be made aware of the advantages and disadvantages of all forms of quitting.
“We need more studies to come to a real scientific conclusion,” he insisted.
Young people in particular seem to turn to e-cigarette use, but it is far from an isolated trend. “It seems to be more popular among young people, but you see people of all ages vaping,” said. Dr Doorley. The difficulty of quitting, combined with the “specific features” that make vaping attractive, have made e-cigarette use the popular choice among all ages.
“Young people are a bit more likely but we don’t have any set data on that. It mimics the pattern and behaviour of smoking, so it probably offers some sort of comfort for people seeking to quit,” according to Dr Doorley. “And it is difficult to quit. Many people make around six attempts to quit.”
However, people who take up e-cigarettes while still smoking traditionally also run the risk of developing a new long-term dependency.
“If you’re going to use them try not to develop a dual dependency. People also may continue to vape long-term after quitting [traditional cigarettes],” Dr Doorley explained. “We [ASH Ireland] would advise people to use e-cigarettes with the intention of quitting eventually.”
Another mistake Dr Doorley said he has seen is attempting to quit with no outside support, be it a nicotine replacement product or counselling. “Psychological support is very important,” he said. “The HSE has support available for all methods of quitting, but one of the mistakes smokers make is trying to quit without any support. You’re less likely to succeed.”
“There’s a drug called Varenicline, which is medication,” Dr Doorley said. “It’s effective, especially when combined with other traditional methods for quitting.”
With much still unknown about the long-term effects, the e-cigarette industry has existed since long before its present widespread popularity. “E-cigarettes have been around longer than people think,” according to Dr Doorley, “but they saw a major increase in 2010.”
The first successful e-cigarette was introduced in 2003, and while there is still little information about their health impacts, there has been an increase in the development of new tobacco products that would seem to cut risk.
“There are other novel products coming out on the main market that are not yet available widespread,” Dr Doorley said. He attributes the tobacco industry’s involvement in newer “heat-not-burn” products to falling sales of cigarettes, especially in western countries.
“They’ve developed a technique for heating tobacco up with no combustion. And in classical cigarettes, it’s the products of combustion that do the harm,” he insists.
Their relative novelty and the lack of information about them make “heat-not-burn” products a sort of wild card. “We don’t know how effective they are because the tobacco industry doesn’t operate with as much transparency.”
Looking forward, there is a lot of uncertainty about whether or not e-cigarette use will continue to rise in popularity. One factor is the varying rates of use across countries. “We don’t know for sure [whether rates will go up or down]. The rate of increase of their use varies in different countries, but it may be slowing down,” said Dr Doorley. “There comes a point when there just isn’t anybody else who wants to smoke.”
According to Dr Doorley, the new products that tobacco companies are developing may push the number of e-cigarette users down as smokers and e-cigarette users alike move to new forms of tobacco.
“Heat-not-burn in some countries is not replacing some of the sales of e-cigarettes, so that may influence the number of people who are using e-cigarettes,” he said. “Some people may choose those instead of e-cigarettes. But certainly, in Ireland, e-cigarettes are very popular and they continue to be.”
Until more research becomes available to better understand the long-term risks and benefits of e-cigarette use, Dr Doorley and ASH Ireland advise looking into all the possible positives and negatives of different methods for quitting.
“The long-term consequences of e-cigarette use are not definite,” he warns. “Other alternatives for nicotine replacement therapy are proven safe and have virtually no major side effects, but we are not as sure about e-cigarettes.
“It’s not a simple issue, but it would be nice to give people a definitive answer,” he said. “Rather than tell people what they should be doing, we want to try to help people to make informed decisions.”