“Is it my fault?” I looked away, trying not to answer my patient’s question. He asked again, “Is the cancer my fault?”
As a doctor, you forget most of your conversations with your patients, but some will stay with you forever. This was one of them.
It was about five years ago and I was explaining the results of a CT scan to a man in his sixties – he had just retired after 40 years as a postman and had become a grandparent for the first time. He was ready to enjoy the wonderful life ahead of him.
Except the scan showed to me that the reason he’d become so short of breath was almost certainly lung cancer, which had spread to his bones.
His life expectancy was probably only a few years; only 9 percent of people in his condition live five years. He held his face with his nicotine-stained fingers and cried as he asked me again if years of smoking had caused his cancer and meant he wouldn’t see his grandson grow up.
Marketed as safer than smoking and as a way to quit standard cigarettes, they contain nicotine but no tobacco, potentially making them much safer
A 2022 review for the Ministry of Health stated, “The government should embrace the promotion of vaping as an effective tool to help people quit smoking tobacco” (file image)
It almost certainly was – smoking is the leading cause of preventable harm, from heart disease to cancer.
The problem is that smoking is so hard to give up. So that must mean anything that can help reduce smoking is a good thing.
And e-cigarettes, which hit the UK market in 2005, are surely the answer? Marketed as safer than smoking and as a way to quit standard cigarettes, they contain nicotine but no tobacco, potentially making them much safer.
Certainly, a review in BMC Public Health magazine in November 2021 concluded that “the use of modern electronic devices for nicotine delivery” [i.e. vaping] can be up to a third as harmful to health as smoking’.
Research like this has been used to push vaping as a way to combat the scourge of tobacco smoking.
Indeed, a 2022 review for the Ministry of Health stated that: “The government should embrace the promotion of vaping as an effective tool to help people quit smoking tobacco.”
And the nation seems to have taken this message to heart – the sweet vapor of vaping vapors has become as ubiquitous as gasoline fumes on city streets.
So why, in a global headline, has the Australian government now effectively banned vaping products unless prescribed? It also introduces quality standards, including limiting flavors and other ingredients.
What do Australians know that we don’t?
The main evidence for vaping comes from a Cochrane review, published last November.
Cochrane reviews are rightly regarded by the medical establishment as the gold standard for assessing the quality of evidence because of the rigor with which they are conducted.
For vaping, the review looked at 78 studies involving more than 22,000 smokers and concluded that there was compelling evidence for the benefits of vaping in smoking cessation.
For every 100 people using e-cigarettes to quit smoking, eight to 12 could successfully quit, compared to six in 100 using nicotine replacement therapy; and four in 100 received only counseling to quit.
In terms of side effects, the Cochrane authors stated that “none of the included studies [which were short- to mid-term, monitoring people up to two years] detected serious adverse events considered to be related to the use of electronic cigarettes’.
With this, it appears we have compelling evidence that vaping helps people quit smoking and that its use should be encouraged.
But just because it’s safer than smoking doesn’t make vaping safe. Indeed, the same BMC Public Health review that provided evidence supporting the safety of vaping has since been updated as the authors’ opinions had changed.
In September 2022, they updated their conclusion by stating that ‘it seems premature to develop quantitative estimates of the relative harms to health from vaping use compared to tobacco smoking’.
In other words, we can’t be too sure how safe vaping actually is.
There were a number of reasons for this change of mind.
The original review did not address potentially important toxins involved in vaping (e.g. formaldehyde and fine particles produced by heating vape liquids).
Indeed, in research published in January 2022 in the Australian Journal of Medicine, scientists made a close analysis of the gases produced when you vaporize liquids used in e-cigarettes and found potentially harmful levels of chemicals, including benzaldehyde and polycyclic aromatic hydrocarbons, which are known to increase the risk of lung diseases such as asthma.
In addition, the original BMC review included data from industry-sponsored research (one study was funded by Juul, one of the largest vaping companies).
It is well known that industry-funded research can be unwittingly biased, which could lead to underestimation of the risks.
And then there’s the length of time people were tracked. Previous studies had only looked at possible short-term damage – usually up to two years – and usually showed no damage. Absence of evidence doesn’t mean it can’t hurt – just that it hasn’t been proven yet.
This is where a report for the Australian Department of Health comes in last April. It looked specifically at the risks of vaping per se and not compared to smoking cigarettes. And the report’s findings are alarming.
The Australian National University researchers concluded that ‘based on current global evidence, the use of e-cigarettes containing nicotine increases the risk of a range of adverse health outcomes, including: poisoning; inhalation toxicity (such as seizures); addiction; trauma and burns; lung injury; and smoking, especially in youth’.
A report by the same researchers in March 2023 concluded: ‘There is strong or compelling evidence that nicotine e-cigarettes can be harmful to health, especially for non-smokers and children and adolescents. Their effects on many important health outcomes are uncertain.’
This is why vaping is being restricted all over the world.
Although China is the world’s largest exporter of nicotine-based vapes, it banned the use of fruit-flavored vapes, which are most likely used by the younger generations for fear of harming their own children.
And earlier this month, Australia announced a ban on the import and sale of all e-cigarettes unless prescription, as well as restrictions on flavours, a shift to plain packaging and new limits on the amount of nicotine in the devices.
The increase in vaping among young people worries me. Last week, survey data showed that the number of 11- to 17-year-olds trying to vape in the UK rose by more than 50 per cent last year.
By the age of 18, 40 per cent of children in the UK have tried e-cigarettes, according to research by the charity Ash (Action on Smoking and Health) – the main reason being ‘give it a try’ rather than helping them quit smoking. This is important – we have a generation that doesn’t necessarily smoke, but vapes.
Take my patient Oli, 30, who happens to be a nurse: She came in a few weeks ago short of breath, with low oxygen in her blood and an increased heart rate.
She told me she didn’t smoke, but vaped socially. I was under the impression (at the time) that vaping was relatively harmless.
I was worried she had a clot in her lungs that was making her short of breath, but luckily a scan showed there was no lung clot.
But there was an explanation for her symptoms: The scan showed “frosted glass opacification of her lung tissue due to a hypersensitivity pneumonitis” — meaning inflammation and damage to the lung tissue. This was caused by the fumes from vaping irritating the convoluted lining of the lungs.
Oli stopped vaping and a few weeks later her lungs were back to normal and she felt fine again.
There is no question that we should allow vaping to help people quit smoking cigarettes. However, we must prevent vaping from becoming so socially acceptable, especially among younger generations.
A good place to start is by following what Australia has put in place: restrictions on its use, so it’s prescription only; a ban on fun, fruity flavors; and simple medical style packaging.
If we don’t, I’m afraid I’ll soon be breaking bad news to a vaper and getting the same question as my smoking patient: “Is it my fault?”
Then, knowing it’s because they were enticed by the “healthier” vaping message, my answer will have to be “yes.”
@drobgalloway