Tom Chivers

Tom Chivers is a science writer. His first book, The AI Does Not Hate You is out now.

September 13, 2019

A shocking statistic. Between them, in the last month or so, smoking tobacco and smoking e-cigarettes probably killed about 40,006 people.

Of course, it wasn’t precisely 50/50. Smoking killed about 40,000 of them; the other six were caused by vaping.

In the average month, about 40,000 people are killed by smoking in the USA, according to the US Centres for Disease Control. Smokers die of “cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis”.

Meanwhile, there has been a huge surge of public interest in the risks of vaping after six much-publicised deaths in August and September. It’s no surprise, then, that the Trump administration is keen to crack down on the e-cigarette scourge, and public health officials are warning of the dangers of vaping.

I am being very slightly unfair here. The six deaths (and the 450 or so severe cases of lung disease) which are being blamed on vaping are apparently sudden acute illness caused by a single dose or small number of doses; the many, many thousands of deaths caused by actual tobacco-smoking are usually chronic illness caused by years of smoking. But still, in terms of the cost of years of life lost, the illnesses and pain and disability, and the burden on healthcare systems, there is absolutely no comparison.

Bizarrely, though, we treat vaping as somehow the same as actual smoking. The signs on train platforms say things like “no smoking, including e-cigarettes”. A constant drip-drip-drip of stories reporting ambiguous findings in mice or in petri dishes has caused undue concern. A survey last year by ASH, the anti-smoking charity, found that while in 2013 only 7% of people thought vaping was as bad as smoking, by the time of the survey, 26% did, and only 13% believed, correctly, that smoking is much more harmful. Another study in the journal Addiction found about the same – that roughly 22% thought vaping was as bad as smoking, and about 3% thought (!) that it is worse.

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For the record: it is not. Public Health England suggests that e-cigarettes are 95% less harmful than real cigarettes. Cancer Research UK and NICE both agree. That’s not to say they’re harmless – they’re probably not. But then almost nothing is, hence all the slightly daft stories about burnt toast causing cancer. So far there is little to no reason to think that vaping significantly raises your risk of long-term chronic illness, and no reason whatsoever to think that if they do, the risk is remotely comparable to the risk of smoking. There is also no good evidence, that I’m aware of, that vaping acts as a “gateway” to real smoking.

But still – those deaths, right? Isn’t it worth worrying about them?

Without wanting to minimise the suffering of the people involved and their families, not really. First, it’s worth being aware just how many people vape now. Somewhere around 9 million US adults do, according to the CDC, and about 5% of UK adults according to the ONS, which is probably around the 2.5 million mark. Six deaths in a population of 9 million is a death rate of 0.07 per 100,000 per year. For comparison, the average American’s annual odds of dying from falling off a ladder is about 0.17 per 100,000 per year, if I’ve done my maths right. I do not think we need, at the moment, to ban ladder-climbing, although of course we should continue to monitor the situation.

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Second – and crucially – as I understand it, the people who have become ill and died were not actually smoking what most of us would consider an e-cigarette. They were, instead, using black market products which heated oil to vaporise cannabis products. Inhaling oil vapour can, apparently, cause something called lipoid pneumonia, which appears to be behind the deaths.

In the UK, under EU law, vape products have to use propylene glycol and glycerine as the carriers for the nicotine and flavourings, which does not cause lipoid pneumonia. You may be able to get the oil-based kind on the black market – I don’t know – but even if you can, it doesn’t seem very likely that cracking down on the legally available kind will stop people using the already illegal ones.

This stuff matters. There is good evidence that taking up vaping helps people quit smoking, according to CRUK and NICE. CRUK has in fact started a public information campaign to try to encourage people to do just that, because the health benefits are clear and obvious.

And yet people who should know better are making a fuss that could cost lives. The American Lung Association’s president issued a statement saying that e-cigarettes are “not safe” and that “no one should use e-cigarettes or any other tobacco product”. He added: “This message is even more urgent today following the increasing reports of vaping-related illnesses and deaths nationwide.”

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The Kansas state health officer said, “It is time to stop vaping… If you or a loved one is vaping, please stop … I’m extremely alarmed for the health and safety of Kansans who are using vaping products and urge them to stop until we can determine the cause of vaping related lung injuries and death.” Trump apparently wants to ban flavourings in vape products.

Let’s imagine that these people are successful in their project and manage to persuade some non-negligible number of people to stop vaping. Then imagine that some number of those people can’t easily stay off nicotine and end up returning permanently to tobacco products. Let’s say it’s a tiny percentage of the total vaping population; 0.1%, or around 9,000 people.

According to the CDC, smoking takes about 10 years off your life expectancy, on average. According to PHE, vaping is about 95% less harmful; let’s naively take that at face value and assume it takes about six months off your life, on average. So those 9,000 people will lose about 85,500 years of life between them, compared to if they’d stayed on the vape. Even if all six of the people who’ve died were 20 years old and healthy and expecting to live another 70 years each, that’s only 420 years of life lost.

So if even 0.1% of the vaping population returns to tobacco permanently, it is reasonable to expect it to be a public health disaster about 200 times worse than the vaping death “outbreak” that we’re seeing now. It won’t be so visible – the deaths will come slowly, in non-dramatic, boring ways, in older people dying in hospices of cancer and emphysema – but it will be just as terrible for each of the people and families involved, and there will be an awful lot more of them.

But still, do tell me about the risks of vaping again, I’m all ears.