In a Puff of Smoke

The year is 1999, and class is about to start at City High. A dozen students linger on the corner of Lowell and College, surrounded by clouds of smoke created by their last-minute morning cigarettes. They crush cigarettes under sneaker heels and head to class, still smelling of tobacco.

“There were a lot of kids that smoked when I went to school here. They’d use the ‘smoker’s corner,’” Michael Close, City alum and current art teacher, said. “It was mainly people that smoked that would park their cars there, and then they would hang out outside their cars and smoke cigarettes before school, and then at lunch time, and then after school, and maybe during open hours.”

In 1999, 23.2 percent of high school seniors smoked cigarettes every day. Fifteen years later, only 6.7 percent of high school seniors reported smoking cigarettes daily. The drop in smoking rates is significant, and factors like aggressive anti-smoking campaigns and increased public awareness of the health hazards smoking presents may have played a role. But as cigarette use has declined, a potential replacement has grown in popularity: 17.1 percent of high school seniors reported e-cigarette use on the same National Institutes of Health survey. E-cigarettes, or more broadly personal vaporizers, first reached United States markets in the early 2000s; little research has been done about their potential health implications, although the body of work is growing.

The term e-cigarette refers to a family of electronic devices that heat and disperse liquids containing flavoring and sometimes nicotine or marijuana oil. They come in three basic varieties: E-cigarettes appear similar to conventional cigarettes and can be refilled with separately purchased cartridges. Vape pens are more expensive to purchase initially, have a longer battery life, and can be refilled with fluid (rather than with disposable cartridges). Modifiers are similar to vape pens, but are customizable, larger, more expensive, and have a longer battery life. Each type functions by using battery power to heat vape liquid, which is first dispensed onto cotton within the device.

“They’re fun, to be completely honest,” Daisy, a City High student, said. “I like to practice tricks. You can make tornadoes, smoke rings, all sorts of stuff.”

Daisy first tried using e-cigarettes, or vaping, as a sophomore. She now vapes almost every day, and she and her boyfriend have begun using a more expensive modifier.

“A good modifier is anywhere from sixty to eighty dollars,” she said. “You can get a lot cheaper or a lot more expensive than that. You can buy a dinky little vape pen for ten bucks and it’ll do fine—perfect for a beginner.”

Simon, another City student, has also tried vaping, although he no longer uses e-cigarettes. For him, cost and health were both concerns.

“I knew that it wasn’t as bad as cigarettes and it you feel kind of cool when you have that going on, like when you’re blowing clouds and stuff,” he said. “[But] it’s kind of expensive to keep going, and it’s just not something that I want to keep doing, especially because I’m a runner.”

A 2015 summary report on studies relating to the health effects of e-cigarette use by the governmental organization Public Health England estimated the risks of using e-cigarettes to be ninety-five percent less than the risks of smoking.

“While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent, and the chemicals that are present pose limited danger,” the report reads.

Nevertheless, e-cigarettes are new enough that the long-term impact of use has not been studied. University of Iowa pediatric cardiologist Tom Scholz has concerns about the possible effects use might have, especially given the current minimal regulation on the contents of commercial vape liquids.

“The thought is that it doesn’t have all those carcinogens that come from the combustion of tobacco. It’s potentially the case, but then whatever you mix in is then going to be aerosolized and then brought into the lungs. So there are compounds that don’t need to be burned that if you get them in your lungs can cause quite a bit of damage,” Scholz said. “Think of all the environmental chemicals that if you inhaled—something like benzene or gasoline or anything—if you inhaled those on a regular basis you’d cause quite a bit of damage to the lungs. The contents are so poorly regulated you don’t know if there are some of these components in there that could be causing lung damage.”

Scholz is also troubled by the lack of research regarding the long term effects of e-cigarette use.

“I think that the fact that you can get them doesn’t necessarily meant that they’re safe and doesn’t necessarily mean that it’s not going to cause some damage down the road,” he said. “One big reason I would discourage anyone from using e-cigarettes is that understanding what you’re putting into your body is not going to be known for quite some time.”

Douglas Hornick, a pulmonologist at the University of Iowa, shares Scholz’s point of view, adding that he is very cautious about any inhaled substances because of the fact that a person’s lungs are directly connected with a their bloodstream.

“With the lungs, you have access to the vascular system or the blood vessels. It’s much easier to get things into the bloodstream when you inhale them than through your skin,” Hornick said. “You’re quite vulnerable to whatever is in that material that you’re inhaling. So I think that’s why we have to be careful about new products like this, that are not well-regulated or where there’s in a way a lot of uncertainties and unknowns.”

For Anthony Fischer, a pediatric pulmonologist at the University of Iowa, e-cigarette flavorings are one specific cause for concern. The flavored components of vape juices are sometimes FDA-approved for ingestion, but not inhalation, according to a report from the CDC. Some have been found to contain chemicals that are harmful when inhaled.

Popcorn workers lung is a form of the serious inflammatory lung disease bronchiolitis obliterans which can be caused by diacetyl, a compound found in some artificial butter flavorings and in more than more than 75 percent of the flavored e-cigarettes tested in a study that appeared recently in the journal Environmental Health Perspectives.

For serious vape users like Daisy, health concerns are something to consider, but don’t outweigh the benefits of vaping.

“I understand the risks,” Daisy said. “I’m aware that they don’t have that many tests that they’ve run on them, that they’re still not sure, but I’m willing to take that risk.”

One way Daisy addresses with the risks she sees in vaping is by making her own juice. She and her boyfriend purchase vegetable glycerin and propylene glycol in bulk, mix them, and add flavoring and nicotine. It costs them about two cents to make a bottle of juice, compared to around ten dollars for commercially sold products.

“They just have any flavor you can imagine,” Daisy said. “We just got jalapeno and tried it, and it was terrible. Disgusting, spicy. We stick to fruits, usually. We do kiwi and peach, or cream and strawberries. Anything you want, really. It’s a lot more changeable than cigarettes are.”

Through the time she spends making juice and otherwise using vapor products, Daisy has experienced the loose culture that surrounds vapers. For example, when she and her boyfriend rode RAGBRAI last summer, they spotted a vape shop and stopped to talk to the owner.

“I think that it’s kind of the same [culture] as the pot smokers,” she said. “It’s a very wide culture, I would say. There are a lot of different categories. A lot of older men I see using vapes because they don’t want to be smoking cigarettes anymore, and again it’s that comfort thing.”

While the vaping community is composed of a variety of people, Daisy uses e-cigarettes primarily in the company of her friends.  

“I think people around my age do it socially,” she said. “It’s a fun thing to do with friends, it makes you look cool.”

Daisy makes her own juice because she enjoys it and because it helps to save money, but also in order to have more control of the chemicals she inhales. Hornick sees this as a potentially safer option, but also a new source of uncertainty.

“I think that potentially it is [safer to mix your own juice] if it’s someone that knows what they’re doing, but the number of people who know what they’re doing—you know, have a chemistry degree or a chemistry background—is probably few and far between,” he said. “Certainly, even myself—I’ve got a chemistry degree—I would be a little nervous if I were making my own brew on a regular basis and ingesting that into my lungs.”

While e-cigarettes have a somewhat ambiguous status in the medical community due to the current lack of research about them, they are generally viewed as more safe and socially acceptable than tobacco products by the general public.

“I’ve heard of people getting caught by their parents a lot, and usually it’s not as big of a deal as if they were actually smoking, because it’s not, in a lot of people’s minds, as unhealthy,” Simon said.

This perception may be one factor that has contributed to the rise in popularity of e-cigarettes, even as smoking rates decline.

“I honestly think the biggest part of why that’s happening is there has been so much research showing how bad [smoking cigarettes] is, and I think kids are getting smarter, too. They’re realizing this is bad for [them],” Daisy, whose parents have both tried vaping, said. “I think [vaping] is 100 percent a safer thing to do than cigarettes.”

Fischer believes that education in school, which is often conducted via programs like Drug Abuse Resistance Education, or DARE, is an effective way of combating tobacco, and potentially e-cigarette, use. However, an article that appeared in the American Journal of Medicine in 2004 found that DARE was in fact an ineffective method of drug prevention, citing very small differences in drug abuse rates between those who had DARE education and those who did not across a meta-analysis of eleven relevant studies. Bigger changes have occurred in the areas of public policy and media portrayal than in education programs, which might indicate other more important causes of the shift away from combustibles and toward e-cigarettes.

Since his high school days, when movies like Pulp Fiction glamorized smoking, Fischer has seen advertisements begin to portray cigarettes more negatively. He believes that the anti-smoking ad campaigns, coupled with high taxes and smoke-free policies have sent a clear message to the public.

“[Recently], the government has done a much better job of regulation [of cigarettes], and providing also a countervailing message against smoking,” he said. “Smoking has become a much more expensive habit, it’s much more difficult to do. I think that one of the reasons that cigarettes are in decline is because of regulation that has been very successful.”

Although some use vapor products as an alternative to smoking combustible cigarettes, for young people, e-cigarettes may simply have the allure of a new and trendy gadget. Daisy believes that this is why she saw a lot of initial enthusiasm for e-cigarettes a couple of years ago, but has since seen it fade somewhat.

“I think a lot of people were very hyped up about it. I think a lot of people were like, ‘Ooh, let’s go to The Den,’ and it was a really fun thing to do,” Daisy said. “I think it’s kind of died off a little bit, as things do”

Several shops in the Iowa City area sell e-cigarette products; The Den and Black & Gold Vapors both declined to comment for this story. However, the number of vapor shops in business is perhaps indicative of e-cigarettes’ current popularity—a rise which Simon, like Daisy, has seen follow a typical trend among his peers.

“It’s gotten a lot more popular, probably because people like new technology and new stuff,” he said. “And this is a new thing that replaces something that is unhealthy and bad, as well as just being something new.”

In fact, results from the CDC’s National Youth Tobacco Survey indicate that e-cigarette popularity has risen steadily for several years: in 2011, 4.7 percent of high school students had ever tried e-cigarettes. In 2012, the number was 10 percent, and in 2013, it was 11.9. By 2014, 27.3 percent of high school students reported ever trying e-cigarettes.

Vapementors.com, a website dedicated to helping vape enthusiasts start their own businesses, puts Millennials at 60 percent of the market share, members of Generation X at 30 percent, and Baby Boomers at only 10 percent. These trends are confirmed by a report from the Centers for Disease Control Public Health Grand Rounds, which showed that 11.7 percent of adults were current vapers in 2013, while 13.4 percent of high schoolers were. Daisy speculates that the disproportionate use of vapor products by young people may be due to different attitudes about new technologies and potential risks.

“I think because it’s so new and we don’t know a lot about it, a lot of adults are more skeptical to try something,” she said. “Teenagers might not care as much about the fact that it hasn’t been studied as much. But I think that in a couple years time, you might see a lot more regular people out on the street vaping.”

Some proponents of e-cigarettes posit that they can be an effective tool for quitting smoking. However, research to support that claim is thin, and the same CDC Grand Rounds report suggests that e-cigarettes may in fact encourage smoking combustible tobacco products.

“The observational study shows that people who use e-cigarettes are actually less likely to quit smoking, so for current smokers, there is a risk that e-cigarettes may prolong nicotine addiction,” Fischer said. “Some people who use e-cigarettes may have a decreased amount of cigarettes that they smoke, but I think that we’re not seeing them turn into former smokers or nonsmokers.”

Another point of concern for Fischer is the fact that a significant share of the e-cigarette market is dominated by major tobacco companies, who have a vested interest in maintaining sales and attracting new customers. Because of this, e-cigarettes are often marketed to young people and nonsmokers.

“The marketing for this is directed very much at [young people],” Fischer said. “It’s not directed at current smokers. They’re advertising in things that teenagers read, like Sports Illustrated or Rolling Stone, and they’re marketed at a younger demographic. In some cases, these e-cigarettes are given away free at things like concerts or for a very low price. They’re trying to get people addicted to nicotine.”

Reports from the CDC also suggest that nonsmokers who use e-cigarettes are more likely to take up smoking than their non-vaping peers. In the study cited, high school students who used e-cigarettes initially were 2.7 times more likely to be combustible cigarette smokers after one year than those who had never used e-cigarettes. Young adults in the same study were 8.3 times more likely to take up smoking after one year if they were vapers than if they were not.

“It’s pretty hard to prove causality in this, but the study that I’m describing was a longitudinal study, and so the people who had been using e-cigarettes subsequently used cigarettes,” Fischer said. “So we can establish a temporal relationship between those things. Whether it be that those are people who would have smoked anyways, it’s hard to say. But it’s important to note that the decline in cigarette use has been going on since the mid 1990s, and this predated the introduction of e-cigarettes. So I don’t see the introduction of e-cigarettes as a reason for the decline in smoking at all.”

E-cigarettes, which originated in China, were largely unregulated when they first reached markets in the United States. Today, they are classified as a tobacco product by the Food and Drug Administration; specific regulations vary by state and city. In Iowa, the sale of vapor products to minors has been illegal since July 2014; the FDA called for such a ban in April of that year. City High administration also treats e-cigarettes as a tobacco product, which usually means confiscating any vapor products found in a student’s possession, and potentially involving the police if the student is caught multiple times.

Daisy, who herself is not yet eighteen, believes that restrictions on e-cigarette sale are justified.

“It think it was a good move [to ban the sale of e-cigarettes to minors],” she said.
“In my own personal experience, it’s not hard to get it from people older than you, and I don’t think minors need to be buying it themselves because that really just opens up way too many doors to nicotine addiction for kids.”

E-cigarette use in public spaces has also faced increasing regulation. In 2015, the University of Iowa introduced a Tobacco-Free Campus Policy that included e-cigarettes on the list of products restricted. To Daisy, respecting other people’s right not to be around e-cigarette vapor is important. However, she doesn’t agree with strict bans.

“I think it’s kind of rude to do it around other people, just like with anything. You don’t want to put on a bunch of perfume and then go out and make people smell that. It’s one of those things that’s a courtesy to other people,” she said. “I think you should be allowed to do it [on campus]. Not in class, but when it’s appropriate.”

While state and local legislation does regulate public e-cigarette use in Iowa City, e-cigarette sales in Iowa do not carry an excise tax the way cigarette sales do. The overall lack of regulation on and knowledge about e-cigarettes concerns Fischer. He is among a growing group of health professionals who advocate caution in trying e-cigarettes, as well as combustible tobacco products.

“I think that the safest thing to do is none of the above,” he said.

While current medical evidence points to some potential risks associated with e-cigarettes, some students, including Daisy, believe that teenagers should stay informed and make their own decisions.

“I would just say be safe and be responsible,” Daisy said. “If you’re worried about it, you probably shouldn’t be doing it.”