E-cigs: How Did We Get Here AGAIN?

This post was authored by Mike Hess, RRT, RPFT

One of my all-time favorite TV shows is Battlestar Galactica. While I grew up with the campy, cheesy original with Lorne Greene shepherding the “rag-tag fugitive fleet” to a new home among the stars, I actually prefer the more recent 2005 reboot. This version took a much more grounded, realistic approach to storytelling and moral discussion. One of the recurring motifs of the show is the phrase, “This has all happened before, and it will happen again,” and ideas like resurrection, learning from history, and breaking cycles.

Unfortunately, this motif seems to have become all too real for anyone involved in the lung health community. I was recently at a meeting of one of our local Better Breathers groups to discuss the upcoming launch of a new Harmonicas for Health program, and the group facilitator had brought some prints of old cigarette ads. The messages on these ads ranged from the clinical (“20,679 Physicians Say “Luckies are less irritating!”) to the risqué (“Blow in her face, and she’ll follow you anywhere”), but a common theme is that certain cigarettes are awesome. They’re what the cool kids like Lucille Ball and Bob Hope are doing, and some of them can actually even be good for you. After all, if the typical smoker inhales 200 times per day, that’s “200 good reasons you’re better off smoking Philip Morris,” right? They’re proven mild! (**NOTE: Most of these ads are available at https://gizmodo.com/14-absurd-ads-from-before-we-knew-cigarettes-could-kill-1499396560 for citation and/or pictures, Hope/Ball ads are at http://exhibits.library.yale.edu/exhibits/show/sellingsmoke/celebrities**)

We know better these days, of course. We know that no cigarettes are healthy, no cigarettes work to improve asthma, bronchospasm, or anything else, and it wasn’t cigarettes that won World War II. We know that these statements are absurd and ridiculous. But we also know we’re seeing the same kinds of imagery and arguments being used right now to support electronic nicotine delivery systems, or ENDS. These devices, more commonly known as vapes or e-cigarettes, are becoming nearly ubiquitous in modern society, much like smoking once was. And, again as in the case of their combustible ancestors, these devices are being sold as an indispensable accessory for an aspirational lifestyle.

The idea of an electronic cigarette first came about in the 1960s. A gentleman by the name of Herbert Gilbert, a two-pack-a-day smoker, decided that combustion was likely the biggest problem with smoking. After all, as he described in an interview, a person could eat certain leaves or barks (like cinnamon) without harm, but as soon as those things were burned, they could cause major damage to the respiratory system (https://www.ecigarettedirect.co.uk/ashtray-blog/2013/10/interview-inventor-e-cigarette-herbert-a-gilbert.html). A few iterations later, an electronic inhalation device was born, promising to not only deliver society from the risks of burning tobacco leaves, but (ironically) to provide other remedies “under direction of a physician” (https://patents.google.com/patent/US3200819).

Despite Mr. Gilbert’s best efforts, no company seemed interested in his new “Smokeless.” The technology essentially lay fallow for nearly four decades, until a Chinese pharmacist by the name of Hon Lik (coincidentally, another smoker) submitted a new patent application for similar device that used ultrasonic vibration to vaporize liquid. No longer ahead of its time (or fighting against as much traditional tobacco advertising), Mr. Hon’s Ruyan device and its many imitators quickly spread across the globe. Whether atomizing via sound waves or more conventional heating coils, this new method of nicotine intake seemed cleaner, safer, and more accessible than old-school tobacco. In addition, because these devices had potential medical applications, they didn’t fall under traditional tobacco regulations (at least, in the United States) and represented a whole new world for tobacco companies to explore and recruit.

Regulation has (slowly) been catching up to the realities surrounding ENDS devices, but in many aspects the damage has already been significant. The widespread availability or (and lack of short-term effects related to) these devices has contributed to a belief that the vapor generated is far safer than any ‘smoke’ from traditional combustible cigarettes. You don’t have to take my word for it; in December 2018, the Kalamazoo County Substance Abuse Task Force conducted focus groups with middle- and high-school students in our area, asking about their perceptions about e-cigarettes. Many of the students who had used these devices felt they were a “healthier alternative to regular cigarettes,” as well as “fun,” “cool,” and made them “look like an adult.” These perceptions have led to a 10% increase in the reported use of e-cigs by high schoolers in the area, with nearly 1 in 3 reporting they had sampled a device within the last 30 days (2018 Kalamazoo Community Report, https://www.prevention-works.org/uploads/4/7/2/8/47288851/prevention-works-community-report-2018.pdf).

Where did these perceptions come from? It seems, in large part, essentially the same place they came from before: advertising. The gap in regulation has allowed the industry to apply the lessons of the early 20th century to modern technology. Instead of Lucy and Desi talking about smoothness, now we see Instagram influencers promoting “cloud competitions,” challenging their audiences to create the largest possible exhaled vapor plume. Current idols and role models are promoting vaping as a safe, healthy activity. Current TV ads even describe certain e-cigarette brands as having “the perfect puff,” and giving smokers more “control.” Sound familiar?

All of this has happened before, but it does not necessarily have to happen again. Even if we clinicians allow for the possibility ENDS devices may end up being a viable tool for tobacco cessation, it seems clear that current tobacco regulations (including advertising restrictions) should also apply to these gadgets. We can learn from the lessons of the early 20th century and reduce the kinds of exposures that led to the COPD epidemic we have on our hands today. We don’t entirely know the long-term effects of vapor exposure, but it seems reasonable to err on the side of health. Promotion of proven, evidence-based strategies for tobacco cessation, as well as reminding our younger population that vapor is not demonstrably any more pure, safe, or clean than combustion by-products, will help prevent an unnecessary repeat of the anti-tobacco efforts of the last 30-odd years, and allow us to devote our resources to more effective management strategies and research efforts. So say we all!

This page was reviewed on February 12, 2020 by the COPD Foundation Content Review and Evaluation Committee