Vaping and a culture that substitutes one risk for another

As Collin Avrard stands behind the counter at Crescent City Vape, a shop that bills itself as NOLA’s best with its “100+ flavors of premium e-liquid, all hand-crafted in the USA,” he’s quick to recommend his favorite flavor: corn bread pudding.

“It has the most outlandish name,” laughs Mr. Avrard, an employee with wire-rimmed glasses whose glinting gold grill matches the gold watch on his wrist. “But it also lands spot-on with what it tastes like.”

It’s one of many e-cigarette flavors that two states have banned this week in response to a number of illnesses linked to the use of vaping devices. 

Mr. Avrard says he first started vaping a few years ago in an effort to be healthy, not cool.

He was determined to quit smoking cigarettes, an addictive habit he started at age 15, he says. At 18, desperate to break an addiction he knew was harming his health and well-being, he started vaping e-liquid pods that contained the same amount of nicotine as a cigarette. He’s now following the “tapering” method to curb and eventually end his addiction to nicotine.

“I started about 12 milligrams and now I’m at 3,” says Mr. Avrard, who says he began to feel healthier within a week of switching. “So I’m starting to work on zero now.”

His ultimate goal is to give up the vaporizer entirely, “even though I am working at a vape shop.”

Indeed, from the moment of its patented origins over 15 years ago, the idea behind “e-cigarettes” – and the technology that would come to be known as “vaping” – were rooted in the heady promise of better health, if not a ready-to-order escape route from one of the nation’s most addictive and deadly vices.

In some ways, the original promise behind e-cigarettes echoes a wider cultural impulse among American consumers trying to battle pleasurable but unhealthy ways, observers say. With an oft-noted faith in technology, Americans saw certain butter-replacing margarines as a way to battle cholesterol and heart disease, and synthetic sweeteners to battle obesity, as well as hosts of other products that claim similar escape routes. All would allow Americans proverbial ways to (literally) have their cake and eat it, too.

Vaping now looks like a major example of how challenging that proposition tends to be. In the past two years it has become more than a cessation tool or a risk-free alternative to smoking, experts say. Spurred on by a pop-savvy industry with sophisticated marketing techniques, vaping has become a cultural phenomenon, an expression of the kind of “cool” that cigarette-makers once sought, especially among teens. 

“That the decline in smoking is giving way to a surge in e-cigarette use and vaping, and that the U.S. has often gone from one drug epidemic to another, each point to the need to understand the more fundamental reasons – perhaps cultural, perhaps economic – that are driving the use of these addictive substances,” says Dhaval Dave, professor of economics at Bentley University in Waltham, Massachusetts, who is researching vaping usage.

Marketing an image

The images of Joe Camel and the Marlboro Man, now banned in most U.S. advertising, has been replaced with the young hipster hitting a Juul, one of the more sleek-looking and popular brands today.

But over the past few weeks, an outbreak of some 500 lung injuries associated with vaping across the United States, including what federal officials say are at least seven deaths, has health experts and government officials sounding an alarm about the little-studied health risks of vaping products. Some are suggesting, in effect, that ingesting the various vaporized chemicals in e-cigarettes may be akin to the unintended consequences of the past, like the introduction of dangerous transfats in butter replacements.

On Monday, the U.S. Centers for Disease Control and Prevention (CDC) activated its Emergency Operations Center to coordinate an interagency federal response, officials said. Last week the Trump administration said it would begin a process to enact a federal ban on flavored e-cigarettes, which have become popular among younger users, after Michigan moved to enact a ban on flavored-vape sales. New York state, as well as the nation of India, imposed similar bans on Wednesday, as California and Massachusetts also consider it.

But regulators should be cautious, too, Professor Dave says, since well-intentioned regulations and initiatives could also have their own unintended spillovers, in this case possibly driving a return to smoking.  

Indeed, the health risk is not the only issue, experts say. There are deeper questions about the motives behind human behavior, the subtle effects of marketing messages, and the complex ways that human beings seek to toggle satisfying physical and emotional cravings and their own health.  

A victory against youth smoking

“We could take a look at more of the larger social and structural influences behind behaviors like vaping and other addicted behaviors, coupled with the ways media influences users’ behavior,” says Yvonnes Chen, professor of mass communications at the University of Kansas in Lawrence, who has studied the impact of vaping ads on adolescents. “When we think about our tobacco control efforts, especially with our youth, we’ve received a lot of success. I mean, fewer and fewer people are smoking now, which really deserves to be celebrated.”

And according to a study this year in the New England Journal of Medicine, smokers who switched to e-cigarettes were much more likely to quit than those turning to nicotine patches, gum, or similar products.

“But now I think the question is whether or not we are masking another potentially addictive product under the label of a quote-unquote ‘healthy’ cessation tool,” says Dr. Chen. “I think that is something that even a lot of researchers are still debating, whether or not that’s true. It’s a very contentious topic in public health.”

Yet as vaping products have exploded across the country, with nearly 11 million users in 2018, much of the increase has come from high school students, experts say. In 2018, 3 million students, or nearly 21% of the U.S. high school population, reported using e-cigarettes – an 80% increase from 2017, according to the CDC.

View from a vape shop

But here at Crescent City Vape, owners and patrons say the outbreak of illness could be seen as an aberration among the millions of people who currently use vaping products. They attribute the illnesses to the underground market selling vaping products laced with THC, the active ingredient in cannabis.

“We’ve had thousands of people come through these doors now,” says Joe Gerrity, the shop’s co-founder. “And over a thousand people have quit smoking cigarettes working with us. We don’t encourage anybody to start vaping unless you are already smoking cigarettes or struggling with a nicotine addiction of another kind. And we encourage everyone to wean themselves off to zero nicotine,” he says.

It’s been five years since Mr. Gerrity got into the vaping business; he’s about to open a fifth Crescent City Vape location in New Orleans. “We consider ourselves to be a health and wellness store,” he says. 

But health experts say that the current state of the vaping industry is like a Wild West of products with differing ingredients and a hodgepodge of additives and infused chemicals. 

“Well, it’s not just those who have been using THC oil or vaping marijuana,” says Dr. Harold Farber, professor of pediatrics in the pulmonary section of Baylor College of Medicine in Houston, noting that many cases were from flavored and nicotine-laced e-cigarettes. 

“If you think, ‘Oh, well, yeah, it’s not the ones that you buy commercially,’ well, there’s no real regulations even on the popular, commercial ones when it comes to quality, safety, what you can put in there, or even good manufacturing processes,” Dr. Farber says.

Apart from the disputes about health and safety, however, many observers note how the idea of vaping morphed from a “cure” from smoking to a risk-free replacement for the same needs and social pleasures derived from smoking.

“We’re repeating history”

“I feel like we’re repeating history when it comes to what’s been happening with the e-cigarette epidemic,” says Melinda Ickes, professor in the University of Kentucky’s department of kinesiology and health promotion. “We saw the tobacco industry use very similar tactics, where they would talk about their products not being that bad for you, and then make it seem like it would be very fun and you can be the ‘it’ person if you are using these products.”

Dr. Ickes points out that while there may indeed be less harm to the body than smoking, that doesn’t mean that vaping is harmless. “And we don’t have enough evidence to even say that they are ‘modified risk’ products,” she says.  

“Yet, while there has been that conversation of the reduced risk of vaping, I think more important in my mind, especially when it comes to addicting youth, is that there’s manipulation going on in the way these products are marketed.”

The e-cigarette technology was first developed and patented by a Chinese pharmacist who was seeking a safer and cleaner way to inhale nicotine, experts note. The pharmacist’s father, a heavy smoker, died after being diagnosed with lung cancer. 

“From 2003, if you see the earlier content and analyze vaping ads, they definitely targeted a lot more smokers trying to quit,” says Dr. Chen of the University of Kansas.

“But the narrative definitely changed,” including to an emphasis on reducing secondhand risks to other people, she says. “And then more recently, they turned to emotional and social appeals. So they include using celebrities, using famous attractive models, and you also see more of a younger appeal. But you also have these sort of outdoor ads, that, while vaping, you’re actually getting in touch with nature.”

As the vaping industry mimics the advertising and strategic playbook of the tobacco industry before the “master settlement” in 1998, in which cigarette-makers agreed to pay out more than $200 billion to cover state health costs and put an end to most of their marketing efforts in the U.S., experts say regulators have to use similar tactics to battle the messages being sent to the nation’s youth.  

“Back in the day, there was a similar mythology around the safety of cigarettes and tobacco. ... The early data on vaping should give us a clue that it’s not quite as safe as people may think,” says Dr. Mark Calarco, national medical director for clinical diagnostics at American Addiction Centers in Brentwood, Tennessee. “Vaping being safer than smoking cigarettes is probably more of an urban legend, perpetuated among the vaping and smoking communities.”

Harry Bruinius reported from New York, and Stephen Humphries from New Orleans.