Insights from a pulmonologist on the 'ever-changing' vaping market

The American Heart Association (AHA) released an updated scientific statement in 2023, highlighting the dangerous misconceptions and lack of long-term data regarding vaping products. In addition, they reviewed how the risk of serious lung injury remains a looming threat.^[]

To dive deeper into this growing area of concern, MDLinx spoke to Jamie Garfield, MD. Dr. Garfield specializes in internal medicine, pulmonology, critical care, and LGBTQ-centered health. She is a professor of thoracic medicine and surgery at the Temple Lung Center at Temple University Hospital in Philadelphia, and a volunteer spokesperson for the American Lung Association. 

Clinicians: Safer is not safe

Dr. Garfield believes that we can become a tobacco-free society. She explained, “There’s an idea of harm reduction and a need for tobacco products that are safer than traditional cigarettes, but safer is not safe. 

According to Dr. Garfield, vaping products aren’t properly regulated and researched. “I think doctors and providers generally don’t know much about vaping,” she said. “And that has to do with a lack of focus on tobacco education and control in medical school. The vaping market is ever-changing. Many of my colleagues don’t know much of what is published in this thorough AHA statement.”

Current regulations and ongoing efforts

Dr. Garfield also highlighted the importance of time when looking for long-term public health data on new products and trends.

“It took decades to understand the disease-causing effects of combustible cigarettes. During a span of almost 50 years, cigarette consumption increased, and the products were even supported by doctors before it became apparent that they caused significant harm,” she told MDLinx.

Reinforcing the sentiment shared in the AHA statement, Dr. Garfield said, “Vaping products only came to market in 2004, so we’re still in the early stages of understanding their impact. And the research trials designed to measure this impact are further muddied by concomitant cigarette use, either currently or in the past.”

Nonetheless, Dr. Garfield cited two regulations that can positively impact public health. “There are regulatory changes that could be imposed to improve the safety of and reduce the number of products on the market,” she said. These regulations are:

• Family Smoking Prevention and Tobacco Control Act (2009):^[] “This law allowed the FDA to regulate tobacco products, but vaping wasn’t included because it was too new. Now the FDA requires these products to prove that they deserve to stay on the shelves, that the benefits outweigh the risks,” Dr. Garfield said.

• Tobacco 21 (2019):^[] “This regulation requires individuals to be 21 years old to purchase tobacco products, including e-cigarettes,” she explained. “There’s been a big push for menthol flavoring bans—a win for the health of the African American community, which is disproportionately affected.”

Dr. Garfield also feels that the AHA positions on these regulations have made a big difference. 

Future research and public health goals

“Unfortunately, there’s too much about these products that we don’t know and not enough regulation to control what’s in them, which makes doing research very difficult,” Dr. Garfield said.

She highlights additional issues, including the problem of “dual use,” in which individuals use both e-cigarettes and traditional cigarettes; the fact that vaping is not the most effective therapy for smoking cessation; inconsistent messaging from providers; and dangerous marketing campaigns from Big Tobacco.

She notes that, currently, the most effective pharmacotherapy for tobacco cessation is varenicline, which she says is more effective than nicotine replacement therapy (NRT) products, but more data is needed. “Varenicline has been studied as a smoking cessation tool for those who use combustible cigarettes. It has not been as thoroughly studied as a cessation tool for those addicted to electronic cigarettes,” Dr. Garfield said, noting a recent study published in BMC Medicine.^[]

When asked how she counsels patients on e-cigarette use, Dr. Garfield said, “I recommend adults who smoke cigarettes to engage in behavioral counseling. They should devise a plan, pick a quit date, be provided resources [such as phone and text support lines], and be made aware of cravings and withdrawal symptoms. If the patient is willing, I recommend combination behavioral counseling along with pharmacotherapy such as [varenicline drugs] or NRT. This is also how I would approach e-cigarette users.”

“There’s no reason to say that the EVALI incidents noted in the AHA paper can’t happen again,” Dr. Garfield warned (EVALI is the clinical diagnosis of “e-cigarette, or vaping, product use associated lung injury”).

“[They] resulted from a market motivated by the consumer and not safety. EVALI took lives, required lung transplants, and produced chronic respiratory failure in otherwise healthy, young patients. EVALI should serve as a warning of what can happen with a lack of regulation and control.”^[]

She went on to explain, “Many vaping devices allow people to modify the way they use these products. For example, they may change the heating temperature or refill them, creating more chances of injury and harm.”