Vaping: The good, the bad and the maybes

When electronic cigarettes, also known as vapes, e-cigarettes, e-cigs, mods, vape pens and so on became available it seemed like the invention many had been waiting for – something that would reduce the huge burden of tobacco products, the leading cause of preventable death in the world.

But are they safe, and are they, as they have been promoted in Aotearoa New Zealand, an effective smoking-cessation aid?

Since 2018 when nicotine e-cigarettes became easily available in this country, they have become remarkably popular, not only among those trying to quit, but among young people who never smoked. The world has seen similar trends, with the US declaring youth e-cigarette use as a national epidemic in December 2018.

It is generally agreed that vaping is less dangerous than smoking cigarettes, but this is yet to be proven definitively, as is how effective they are as a smoking-cessation aid.

The rapid evolution of vaping technology and the range of liquids used inside these devices means we don’t always know what is being inhaled when vaping. Just as it took decades to prove that smoking caused lung cancer and a number of other diseases, by which time it was too late for many, it will take time to understand how vaping affects our health.

The appeal of e-cigarettes is unsurprising in many ways – they’re considerably cheaper than cigarettes, they have become more socially acceptable, partly because they don’t smell as bad, they’re easier (particularly for young people) to buy, they allow for the ‘puffing’ activity, which for many is what made cigarettes so popular, and they actually taste pretty good.

E-cigarettes often contain nicotine, which is an addictive substance, and while there are less chemicals in e-cigarettes the inclusion of nicotine suggests they are addictive. And common sense tells us that inhaling a heated combination of propylene glycol, glycerin, flavourings and other (often unknown) chemicals over the long term is unlikely to be good for our airways, our lungs or our heart.
 

We have tested 20 different NZ-made e-liquids consisting of three different brands of tobacco, menthol, and mango flavoured e-liquids with different amounts of nicotine. We found more than 140 different flavouring chemicals in these e-liquids. It has only been since August 2022 that these chemicals have had to be listed on the bottles. We also found formaldehyde (a known carcinogen) in the vape created, and some metals, including silicon in the liquids and iron, zinc and chromium in the aerosol. It’s too soon to understand how these chemicals are interacting with the cells in our body.

Different countries regulate e-cigarettes in different ways, depending on whether they focus on their potential harms for the population as a whole, or their potential impact as a harm reduction tool for smokers. New Zealand is taking the latter approach, to support our collective journey to a Smoke Free Aotearoa, so vaping products are still visible in vape shops, dairies and petrol stations, where cigarettes are now hidden from view.

A large Cochrane review done in 2021 concluded: “Nicotine e-cigarettes probably do help people to stop smoking for at least six months. They probably work better than nicotine replacement therapy and nicotine-free e-cigarettes. They may work better than no support, or behavioural support alone, and they may not be associated with serious unwanted effects”. (The review authors noted that the longest follow‐up was two years, and the number of studies was small.)

The evidence collected in this review showed that the use of e-cigarettes with nicotine could potentially increase quit rates by about three to eight people per 100 people trying to quit.

As the Government is promoting e-cigarettes as a useful tool to quit smoking, we looked at what people in New Zealand were choosing to use in their own personal quit journeys, how those who chose to vape were doing six months after quitting (smoking) and whether they would recommend the use of e-cigarettes to others.

We compared the use of smoking cessation aids across different ethnic groups and age groups within a large New Zealand cohort and assessed the uptake and effectiveness of e-cigarettes for smoking cessation via a "vape to quit" initiative, using data from Te Hā – Waitaha, a smoking cessation service in Canterbury which prioritises recruitment of Māori, Pacific and pregnant people.

Participants who enrolled in the Te Hā – Waitaha programme could choose medicines, such as Varenicline, known as Champix, or nicotine replacement therapies, such as patches, nicotine gum and lozenges, nicotine sprays and inhalers, or e-cigarettes, with and without nicotine. Our analysis of more than 1,000 people showed that nicotine containing e-cigarettes had, since 2018 when they became available, become the most popular smoking-cessation aid with 65 percent of each group choosing them to support their aim to quit.

We followed up 100 participants who had used the “vape to quit” option and found that after six months 16 of those people were smoke and vape free, 31 were smokefree and vaping, 31 were smoking and not vaping, and 22 were smoking and vaping.

While this is a small study, it indicated that nicotine containing e-cigarettes have potential in smoking cessation programmes, but they don’t work for everyone. While 56 of the 100 people recommended the use of vaping for smoking cessation, the rest wouldn’t because it [vaping] was “not satisfying enough” or was “swapping one habit for another”.

That 22 percent of the "vape to quit" people we followed up had become dual users – were smoking and vaping - is concerning. There is evidence that dual use could be as or possibly even more harmful than one or the other, exposing people to a wider range of chemicals. More research is needed to fully understand how effective vaping is as a smoking-cessation tool, and also the potential dangers.

While vaping is showing promise in supporting smoking cessation, it isn’t the “silver bullet” that we might have hoped for and smokers trying to quit likely need other support to become smokefree. Our advice is, if you’re a smoker switch to vaping, but regard it as a short-term strategy and aim to quit both smoking and vaping, but if you are not a smoker, don’t start vaping!