Is Vaping with E-Cigarettes as Dangerous as Tobacco Addiction?

Some digital tools can be damaging or life-threatening. Electronic cigarettes, or e-cigarettes, are portable electronic devices that produce vapor by heating an inhaled liquid containing nicotine, among many other potentially harmful compounds. As of 2020, there were an estimated 68 million e-cigarette users worldwide. Although e-cigarettes are often marketed as a safer alternative to traditional tobacco products (2017), scholarly controversy continues. Many parties have proposed alternatives to tobacco products for decades, but none have been as successful as the tobacco industry’s efforts to diversify into e-cigarettes. This article will provide relevant facts, discuss the repercussions of using e-cigarettes from the perspective of tobacco addiction, and review a recently published journal article.

Tobacco Addiction Facts

Let’s start with tobacco, then look at how e-cigarettes fit into the picture. A May 2022 statement published on the World Health Organization (WHO) website states the following:

• Tobacco kills up to half of its users.
• Tobacco kills more than 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use, while around 1.2 million are the result of non-smokers being exposed to second-hand smoke.
• Over 80% of the world’s 1.3 billion tobacco users live in low- and middle-income countries.
• In 2020, 22.3% of the global population used tobacco, 36.7% of all men and 7.8% of the world’s women.

E-Cigarette & Vaping Facts

The process of using e-cigarettes is known as “vaping” and has been marketed heavily to vulnerable groups, particularly children and teens. Factors that increase the appeal for children and teens to vape include:

• Peer influence
• Flavorings including fruit, bubble-gum, candy, method, and other pleasing tastes
• Curiosity and experimentation with electronic equipment, as is typical for youth
• Aggressive advertising and marketing by vaping and tobacco companies that benefit from recruiting life-long tobacco users 
• Lack of awareness of the risks of vaping due to nicotine and chemical contents being inhaled into one’s lungs
• Perception of reduced harm if risks of nicotine are realized.

E-Cigarette Liquid

The liquid used for vaping is known as “e-liquid” but is also known as e-juice or vape juice. E-liquids may contain nicotine, propylene glycol (PG), vegetable glycerin (VG), and sometimes water. Flavorings are added to satisfy various preferences, such as menthol, fruit, dessert, candy, or bubble gum, which are particularly appealing to children and teens. 

Names for E-Cigarettes

E-cigarettes are interchangeably called “e-cigs,” “vapes,” “e-hookahs,” “vape pens,” and “electronic nicotine delivery systems (ENDS).” Some resemble traditional cigarettes, cigars, or pipes. Some look like USB flash drives, pens, and other everyday items. They all involve an electronic component that must be charged, usually with an electronic port, such as a USB port.

Damage Caused by E-Cigarettes

The WHO webpage about e-cigarettes details the different types and severity is problems associated with e-cigarettes. Those dangers are summarized in the following WHO statement: 

There is growing evidence that ENDS could be associated with lung injuries and in recent times e-cigarette and vaping have been linked to an outbreak of lung injury in the USA. This is described by the United States Centers for Disease Control and Prevention (CDC) as e-cigarette or vaping associated lung injury (EVALI), which led the CDC to activate an emergency investigation into EVALI on 17 September 2019.

The CDC notes, “As of 18 February 2020, there have been a total of 2,807 cases of EVALI reported from all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands, including 60 deaths confirmed in 27 states and the District of Columbia. While the cause of these deaths has not been conclusively determined, vitamin E acetate (VEA), a common additive in ENDS that contains cannabis (or THC), is thought to have played a significant role in these cases of lung injury. Further information on this incident, including a strong link of the EVALI outbreak to Vitamin E Acetate and the latest report, which is updated every week, as the evidence is not sufficient to exclude the contribution of other chemicals.

Nicotine Addiction & E-Cigarettes

E-cigarettes typically contain nicotine, a substance known to cause dependency (2019). The World Health Organization categorizes e-cigarettes as “addictive and not without harm” (2022). However, inconsistent findings regarding the health and addiction risks associated with e-cigarette use have persisted for almost a decade (2015). A growing number of studies suggest the addictive potential of e-cigarettes (2017, 2018, 2020).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes tobacco use disorder but has not been updated to include vaping with e-cigarettes.

However, Tobacco Use Disorder can be diagnosed when symptoms include the following:

1. Tobacco is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.
3. Much time is spent on activities necessary to obtain tobacco, use it, or recover from its effects.
4. Craving, or a strong desire or urge to use tobacco.
5. Recurrent tobacco use results in a failure to fulfill role obligations at work, school, or home.
6. Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco.
7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use.
8. Recurrent tobacco use in situations in which it is physically hazardous.
9. Tobacco use continues despite knowledge of a persistent or recurrent physical or psychological problem likely caused or exacerbated by tobacco.
10. Tolerance is defined as either 1) a need for markedly increased amounts of tobacco to achieve intoxication or 2) the desired effect or a markedly diminished effect with continued use of the same amount of tobacco.
11. Withdrawal, as manifested by the characteristic withdrawal syndrome for tobacco or tobacco (or a closely related substance), is taken to relieve or avoid withdrawal symptoms.

A diagnosis of Tobacco Use Disorder is made when at least two of these criteria are met within 12 months.

Recent E-Cigarette Study

Given the research gap of whether or not the use of e-cigarettes can be considered as serious as tobacco addiction, researcher Daria Szafran and colleagues used a netographic¹ approach to investigate the issue. Their study was published in the Journal for Medical Internet Research (2023). They focused on whether and how e-cigarette users subjectively perceive typical addiction signs based on the DSM-5 criteria for tobacco use disorder. Called the Evaluation of the Addictive Potential of e-Cigarettes (EVAPE) project, the researchers analyzed current data from German-language online forums dedicated to e-cigarettes. Many people consider vaping a hobby and actively share their experiences on online forums, social media platforms, and conventions. 

Results

The researchers screened 5,337 threads across three online community discussion forums and found 451 threads that contained pertinent information for their analysis. E-cigarette users shared experiences that align with DSM-5 tobacco dependence criteria, including craving e-cigarettes, spending excessive time vaping, and experiencing health problems associated with e-cigarettes. The perception of not being addicted was primarily reported compared to previous tobacco smoking experiences.

Conclusions

The researchers concluded that while some users reported subjective experiences that aligned with the criteria for tobacco use disorder outlined in the DSM-5, not all users exhibited these symptoms. Interestingly, they also reported that users frequently discussed the absence of such symptoms, and in the majority of cases, reports of absence outnumbered reports of presence.

In their closing remarks, the researchers commented that self-reports cannot be used as a clinically reliable means of diagnosing tobacco use disorder. They concluded that a subset of e-cigarette users reported signs comparable to the DSM-5 criteria for tobacco use disorder.

Discussion

The cautious clinician working with children, teens, and adults may consider asking about vaping behavior as part of the intake process. It may also be advisable to keep an ear open for clues of regular use, even if denied at intake. The clinician may reasonably consider motivational interviewing techniques if nicotine addiction is detected in e-cigarette use. Once motivated, vapers can be referred to local tobacco addiction services, as treatment and recovery processes are likely similar. 

Children and teens drawn by the technology aspect of e-cigarettes may be similarly drawn to the technology of virtual reality. Clinicians interested in exploring the possibilities are encouraged to contact companies that already produce technology for other problems experienced by children and teens and to adhere to device sanitation protocols.

• Nicotine treatment resources are often available at county American Lung Association branches and some local hospitals. 
• The Center for Disease Control & Prevention (CDC) links to the 1-800-QUIT-NOW hotline, which has had 15 years of success in helping people to quit at no cost. It is the national portal to a network of state quitlines.
• Nicotine Anonymous is a 12-step recovery program focused on helping people struggling with all forms of nicotine addiction. Twelve Step program enthusiasts may want to note that nicotine addiction denial runs deep. Both Dr. Bob and Bill W died of nicotine addiction. They were the founders of Alcoholics Anonymous.

The first step is asking about vaping (and other nicotine use) at intake. 

Footnotes

¹ Netnography is a research methodology that adapts ethnographic study techniques to study online communities and digital cultures to understand the digital culture’s social dynamics, norms, behaviors, and beliefs. It can limit the social desirability bias that can complicate face-to-face research, such as focus groups.