By Sally Satel
The controversy surrounding electronic cigarettes continues to smolder. E-cigarettes are the battery-powered devices that deliver an aerosol that contains nicotine but no trace of cancer-causing tar. Despite ample data to the contrary, critics insist that e-cigarettes are a “gateway” to teen smoking and that they contain dangerous levels of toxins. Meanwhile, the Food and Drug Administration has yet to issue regulations.
Things may seem stagnant – the same debates, the same anxieties about pending regulatory over-reach – yet researchers are busy. New data from Scotland underscore how e-cigarettes are helping smokers quit, saving millions of lives and untold health care dollars. More exciting, they suggest an untapped way to spread e-cigarette use, or vaping, to smokers who might otherwise not try to give up their deadly habit or who have failed using traditional means.
In a new survey, psychologist Christopher Russell and colleagues at the Centre for Drug Misuse in Glasgow collected a large pool of data from vapers. The Centre, an independent research entity that collects epidemiological data on substance abuse and harm reduction efforts, and performs policy evaluations, has received research funding from public bodies, such as the UK Government Department of Health and the United Nations, and from tobacco companies, such as British American Tobacco and Philip Morris.
Russell ran an online poll, conducted over 12 weeks last summer, of 7,300 people who said they had vaped at least once. Of those, 5,000 had been regular smokers when they first tried vaping. Russell’s data show overwhelmingly that vaping helps smokers quit. More than 80% of smokers had quit completely since they started vaping regularly, which, at the time of the survey, was an average of 14 months before they took the survey.
Of the respondents who were still smoking at the time of the survey, more than 56%, had at least halved their daily smoking since starting regular vaping (defined as at least every other day). The average reduction was from 23 cigarettes per day pre-vaping to four per day.
To round out the picture of the experiences and motives of vapers, Russell asked a litany of questions: What was their experience with flavors and nicotine strengths; their reasons for vaping; their perceptions of harm relative to cigarettes, their perception of addictiveness of e-cigarettes relative to cigarettes, health changes they have personally experienced since initiating vaping? Then came the question with real public health power: “What could smokers, who are curious about using e-cigarettes to quit smoking, learn from vapers who have quit or significantly reduced their smoking by using e-cigarettes?”
The most common piece of advice concerned the importance of finding the right device and flavor for the user. Other advice included “don’t start with a cig-a-like [the weaker versions that look like cigarettes]. Rather, start with a newer generation device,” “ask for expert advice,” “do not expect a cigarette experience.”
Here’s where Russell’s survey spurs an idea that could start saving lives tomorrow: Why not assemble a loose network of potential vaping sponsors? True, some vapers communicate informally with smokers already, but if we can build a vaper-smoker buddy system into the public health landscape, we can further arm the fight against smoking.
The local health department or area hospitals could run public service ads on TV or radio and post billboards advertising the availability of vaping buddies (or sponsors, navigators, etc). A website would contain the name of local vapers who volunteer to serve as sponsors or direct smokers to local vape shops where those names would be listed, too.
Civic-minded vapers could sign up to be sponsors through the local vape shop or health department. Their names could be posted at the nurses’ station of emergency rooms and circulated to local primary care doctors who can urge their smoking patients with COPD and other smoking-related conditions to pair up with someone on the list.
It need not be a long-term relationship, but it would be a great way to introduce a patient to vaping if his or her physician determines that the patient intends to keep smoking for the foreseeable future or has had little to no success in quitting with the help of conventional anti-smoking aids.
People grappling with alcohol and drug problems routinely have sponsors as part of their involvement with Alcoholics Anonymous or Narcotics Anonymous. Although most smokers don’t need long-term support groups, they need awareness of alternatives, access to them, accurate information, and encouragement.
After all, a vaping sponsor can provide the same benefits that have helped so many others quit alcohol. As Stanford University psychologist Keith Humphreys, a scholar of addiction recovery self-help groups, notes, “a large number of studies identify ‘active ingredients’ of AA’s effect, as role models for change, greater social support, better coping skills, greater self-confidence, and more motivation to change.”
Unlike many abusers of intoxicants, nicotine-dependent people don’t need to learn to live without a drug, they need to learn to use it in a safer form. They need practical advice (best local vape shop, how to maintain equipment, how to find high quality e-liquid); they need to know what they can expect (e.g. that dual use – vaping while continuing to smoke, at the beginning is very common) and which puff techniques lead to maximal satisfaction. They need a fair assessment of the known and unknown risks associated with alternatives to cigarettes and some need general motivational support if they are ambivalent about relinquishing cigarettes.
The day-to-day policy implications of these observations in combination with known facts about behavioral change argue for a number of strategies.
Take public vaping. Vaping has already been banned from offices, public parks, restaurants and airports. But at the very least, it should be allowed in non-smoking adult establishments with well-marked vaping areas. While not emission-free, any “second-hand” vapor that wafts several feet, unlike smoke from a cigarette, will be virtually undetectable as the subtly “flavored” odors dissipate rapidly. Studies show that emissions, such as propylene glycol, formaldehyde, and acrolein, are at negligible levels, thus below clinically meaningful thresholds for otherwise healthy bystanders.
The idea is for people who smoke to be exposed to vapers as often and as visibly as possible. The infiltration of vapers into non-smoking environments where there are temporarily abstaining smokers (that is, smokers who are, at the moment, banned from lighting up) is a great way to spur curiosity and conversation about vaping.
For non-smokers, the difference between vaping and smoking should be reinforced in every way possible. That difference should make vaping look more attractive than smoking. For example, airports should have attractive vaping lounges. Smokers should still have to go outside.
There is a large literature on what people need to do to change a well-established habit. If we want people to stop smoking, we’re likely to engage them more successfully if there is a feasible replacement available. In the case of smoking, it’s vaping. Not only that, the smoker needs a sense of “self-efficacy,” the confidence that he or she can engage in the replacement activity and be successful at it. Showing someone how it’s done, answering questions, reducing uncertainty is an excellent way to do that.
I’m excited to see how Christopher Russell turns established vapers into assets: what strategies does he use and how successful is he? I’m optimistic. The “vaping sponsor” – my term – aspect of his project will start in December. As he says, “To dismiss, misuse or under-use these individuals’ insights and experiences as part of health services’ efforts to engage with smokers would, in my opinion, be a monumental missed public health opportunity.”