Up in Smoke

Dan Ward is 27 and lives in Pittsburgh’s Garfield neighborhood. He is mostly vegan, rides his bike to work and walks in the park as often as he can. He also vaped for several years, using an electronic cigarette to satisfy a need to “have one vice to balance my otherwise healthy lifestyle.”

Diane Lavsa is a “very happy smoker.” The 39-year-old, who lives in Etna, smoked cigarettes for 18 years and is not shy about explaining why. “I loved smoking. I love the taste of it. I don’t mind the smell of it.” She, too, turned to e-cigarettes, trading in clouds of smoke for a faint burst of fruity nicotine-laced vapor as she tries to distance herself from the tobacco she so enjoys.

Vaping has gained a foothold in American culture after decades of steadily falling cigarette smoking rates, worrying public health experts that its popularity could rekindle a craving for tobacco, particularly among adolescents and teens.

In September, the Food and Drug Administration declared that teen use of e-cigarettes has reached “an epidemic proportion” and gave Juul and four other major manufacturers of e-cigarettes 60 days to prove they are keeping the products out of the hands of minors or else they may pull the products off the shelves.

E-cigarettes are popularly seen as a safer alternative to cigarette smoking and an aid to smokers trying to quit that lacks many of the harmful chemicals that burning tobacco emits, such as tar. The health benefits and risks of vaping, however, are not well understood. And most e-cigarettes contain nicotine, which is addictive and harmful to fetuses and developing adolescent brains.

Cigarette smoking in southwestern Pennsylvania is down 25 percent since 2011. But adults in the region are vaping at a rate that’s 53 percent higher than the national average, according to U.S. Centers for Disease Control and Prevention health survey data.

“I think we were on a trajectory that could have seen the end of smoking. Attitudes had completely changed,” said Dr. Brian Primack, professor of medicine, pediatrics, and clinical and translational science at the University of Pittsburgh. “The e-cigarette phenomenon is a boon to the industry because they’ve been able to change attitudes. People no longer think of nicotine as a bad thing. Instead, young people say, ‘If it’s available in mango and it doesn’t have all the bad stuff in it, it must be OK, right?’”

Loosening tobacco’s grip

The decline of cigarette smoking is traced to a number of developments, such as greater public awareness of its health risks, heavy taxes on tobacco products, anti-smoking campaigns, tighter regulations on the industry and its marketing and restrictions on where smokers can smoke.

Nationally, about 15.5 percent of adults smoked in 2016, according to CDC data. Rates have even fallen in the seven-county Pittsburgh Metropolitan Statistical Area, where smoking has historically been higher than the national average. Smokers account for 17.4 percent of adults in the region, down from 23.31 in 2011.

“The good news is the trend is going in the right direction,” said Dr. Karen Hacker, director of the Allegheny County Health Department. “There’s a lot of evidence out there that the two things that do the most to really pull your smoking rate down are bills like the Indoor Clean Air Act and other regulations, and the cost of cigarettes and tobacco taxes.”

Taxes on cigarettes hit local smokers hard. Pennsylvania has the 11th highest state tax at $2.60 per pack of cigarettes, well above the national average of $1.71 per pack.

But many of Pittsburgh’s peer regions benchmarked by Pittsburgh Today have stronger indoor smoking laws, which allow them to more strictly limit where people can smoke in public. In Allegheny County, there are 437 establishments exempt from the Indoor Clean Air Act. “While we have public spaces that are no smoking, you can smoke in many bars. You can smoke in a casino, you can smoke in a club,” Hacker said.

More people are vaping as well. It’s something 4.9 percent of the region’s population say they do regularly, compared to 3.2 percent of all Americans, according to CDC data.

New industry rising

Americans have been looking for a safer smoke since the 1960s, when the U.S. surgeon general began linking cigarette smoking to lung, heart and other serious diseases. The tobacco industry responded with “light” cigarettes, marketing their lower tar and nicotine content as safer. E-cigarettes embrace the same image with some justification.

E-cigarettes don’t burn tobacco, but heat chemical juices to produce vapor. A National Academies of Sciences, Engineering and Medicine report released earlier this year concluded that e-cigarette vapor contains fewer numbers and lower levels of harmful chemicals than burning tobacco.

Most e-cigarette vapor, however, contains nicotine. In addition, e-cigarette production is unregulated; levels of nicotine and other chemicals in e-cigarette vapor vary and are hard to determine and scientists are only in the beginning stages of investigating their health effects.

At the moment, the percentage of U.S. adults who’ve turned to vaping is small. But it’s much more popular among adolescents and teenagers.

A 2017 study by the CDC found that 50 percent more high school and middle school students vape than smoke. In Allegheny County, 20 percent of teens had tried e-cigarettes and nearly 10 percent were vaping in 2014, a Health Department survey found.

“When you look at traditional tobacco products, you see a decline in usage. But when you add e-cigarettes, you see a slight increase in the youth who are using tobacco and part of that is marketing,” said Brittany Huffman, program coordinator for Tobacco Free Allegheny, a tobacco-use prevention nonprofit. “They’re using the same kind of marketing tactics they successfully used with traditional cigarettes: If you use this product, you’ll be sexy. You’ll be glamorous. If you don’t, look at the great time you are missing out on.”

And there is a coolness factor in some corners of the vape subculture. Vape cloud competitions have popped up across the country and on YouTube, in which competitors try to exhale the largest and most creative cloud of vapor—waves, orbs, rings, etc. Teens post videos and images on social media of their own vape tricks to gain followers and influence.

That’s less of a turn-on for some older users and even young adults such as Ward. He smoked cigarettes for about five years before giving them up to vaping. He quit vaping after a couple of years, in part, because he felt it had become uncool.

“The subculture that was growing was not appealing to me,” he said. “I was ashamed to use it in public sometimes. Not because people would shame me, but because I’d feel like an idiot. It got to a point where I would only do it at home or when I was walking by myself.”

Cessation aid or gateway drug?

E-cigarettes helped Ward quit tobacco, but research into their effectiveness as a smoking cessation aid is inconclusive.

Vaping, for example, might be as effective as nicotine patches in helping people quit smoking for at least six months, according to a 2013 study published in the medical journal Lancet. But a 2017 study in the American Journal of Preventive Medicine found smokers who also use e-cigarettes were only half as likely to give up tobacco as smokers who never vape at all.

E-cigarettes have not been approved by the U.S. Food and Drug Administration to be sold as a smoking cessation product, such as patches and gum. “We know that those products when used as directed can be used to quit smoking,” Huffman said. “They have studies behind them. The concern with e-cigs is that they aren’t regulated. You don’t really know the amount of nicotine you’re getting when you use an e-cigarette.”

And the nicotine factor is critical, public health officials say. “The truth is, nicotine is one of the most addictive substances we know of,” Primack said. “It’s damaging to the adolescent brain by itself. And we found in our research that being exposed to it in teenage years makes one much more likely to take up regular cigarette smoking later on.”

He was the lead author of a 2017 study published in the American Journal of Medicine that found young people who vape to be more than four times more likely to start smoking tobacco cigarettes within 18 months compared to those who don’t vape.

“The truth is, nicotine is one of the most addictive substances we know of. It’s damaging to the adolescent brain by itself.”
—Brian Primack, MD, professor of medicine, pediatrics, and clinical and translational science at the University of Pittsburgh

Another recent study in the journal JAMA Pediatrics also found e-cigarette use raises the risk of graduating to cigarettes, and this year’s National Academy of Sciences study reports “substantial evidence” that youth and young adults are more vulnerable. Moreover, the number of teens and young adults who graduate from vaping to cigarettes is much greater than the number of adults who use e-cigarettes to quit smoking, according to a new study published by the Public Library of Science.

“When the data come out and there is an FDA approval that vaping is a strategy for quitting smoking, we are happy to support that strategy,” Hacker said. “On the other hand, there is ample evidence out there that if you’re a young person and you start with e-cigarettes you are likely to move on to cigarettes. We do not want to see that.”

Last year, Allegheny County began prohibiting the use of e-cigarettes and vaping in indoor public places where cigarettes are already prohibited. “We don’t want to change how people are currently experiencing smoke-free environments, and that’s important to how young people would visualize this as well,” Hacker said.

For Lavsa, vaping has been an effective, but unsatisfying alternative to cigarettes. She still takes smoke breaks at work, but vapes in her off-hours. She fell in love with a non-smoker and picked up vaping to survive a weekend with his family where she had to hide the fact that she smoked.

But the transition hasn’t been easy for the former pack-a-day smoker. “There are still those moments when I’ve just had a big cup of coffee or I’ve just had a big meal and I want a cigarette. That hasn’t gone away. There’s an urge to have a cigarette in your mouth. Vaping doesn’t have that feeling or that taste in your mouth or the smoke. But what I love so much is I can go to Kennywood and, if I’m jonesin,’ I can take a puff of a vape and people aren’t turned off by it.”