Joey Wahler (Host): Vaping's popularity has grown, so we're discussing whether it's really better for your health than cigarette smoking. Our guest, Dr. Kristopher McDonough. He's a pulmonologist with Silver Cross Hospital.

Welcome to Silver Cross Hospital's IMatter Health podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. McDonough. Welcome.

Kristopher McDonough, MD: Joey, thanks so much for having me. I really appreciate your time.

Host: Same here. Great to have you aboard. So first, for those unsure exactly, you've simply heard about it, what is vaping and how common is it these days?

Kristopher McDonough, MD: So, vaping is a way that people can use nicotine or other substances in a way that's different than typical combustible tobacco products. So, the way that we can use nicotine by taking a liquid that has nicotine within it, heating it up until it turns into a mist or an aerosol and then breathing it into our lungs without setting it on fire in the way that we would do with normal combustible tobacco products.

It's pretty popular. It's increasing in frequency sort of throughout the United States and really across the world. Somewhere around one in five adults over the age of 18 is at least an occasional user of a vape or an e-cigarette. And that number is particularly significant when we look at younger adults. It's more than double the frequency of use in that population of people between the ages of 18 and 24. So, pretty significant thing out there when we're talking about all adults between the ages of 18 and 24 using these substances.

Host: Wow. And so, it used to be years ago that some young people would try to look cool by smoking or even just holding a cigarette and now it's vaping instead, right?

Kristopher McDonough, MD: No doubt about it. There's a lot of social pressure that comes with this to your point. And it is absolutely something that sort of, no pun intended, spreads like wildfire amongst this population of people.

Host: Indeed. And so, what are some of the main differences between vaping and smoking?

Kristopher McDonough, MD: I think we're all pretty comfortable with typical combustible tobacco products. When we talk about smoking, we usually think of cigarettes, although certainly pipe smoke would be a different way look at that. But when I say that I'm going to mostly talk about cigarettes, we're all pretty comfortable with that. We've seen it for most of our lives, and we are aware that cigarettes are really, really bad for you, right? And so when you take a cigarette out of the pack, you light it up, you smoke it, and then you get rid of the butt when you're done.

Vaping is a little different. A vaping pen or an e-cigarette, and there are a variety of these devices that are out there, that is a thing that you carry around in your pocket or your purse or your backpack. And it has a liquid inside of it. That liquid usually comes with a solvent and some nicotine or something else that you're going to be inhaling. And you pull it out sort of time over time. It has a rechargeable battery typically, although there are some that have just replaceable batteries. And that's an item that you can carry around with you kind of all the time. And it's the same one that you had the morning and the afternoon and the evening, so a little bit different than a typical cigarette.

Host: And so, that whole picture that you just painted, that supports the idea that vaping is less dangerous for your health than smoking. So of course, it begs the question for an expert like you, is that really so?

Kristopher McDonough, MD: Yeah. I think that there's a lot of things to unpack with that statement, right? And I think when we think about the relative safety of a substance, I think we need to consider who it is that we might be talking about using that substance and whether we're talking about sort of immediate effects or late effects of a substance.

And so if I can sort of go through that, I think the difference between say a 17-year-old or a 19-year-old using a vape pen or an e-cigarette or a Juul type device and an older adult who is quitting smoking with a vaping pen. I think it's a very different set of circumstances. And I think, you know, we can certainly talk about those things at depth. But one of the things that we can really look at is in that younger individual, there are two major issues.

One is we're really uncertain about what the long-term effects of these things are, you know, over a long period of time. It's not as if these substances or these devices have been around for 30 or 40 years, right? They've been around for 15 years, by and large. We're really uncertain about that in our younger population. And the second thing for a younger population is this is really an entry point into use of combustible tobacco products. And I think we'll probably talk about that later on.

In adults who have been cigarette smokers and are using an e-cigarette as part of a smoking cessation process, I think the health ramifications are a different consideration. If we can get people off of combustible tobacco, away from their cigarettes, there may be some utility in that. I don't think any of us are saying that this is a great long-term answer for you. But in the short term, if we can get you off of combustible products, then maybe in fact there might be some health benefits there. Not that the e-cigarettes are healthy for you, I don't want to confuse that, but smoking cessation in and of itself is perhaps the most important thing that someone can do for their health.

Host: It seems like what you're saying there in a nutshell is that you're basically more sure that it's a solution to improving things for an older person as opposed to a younger one. That's simple, right?

Kristopher McDonough, MD: Yeah. So, I think the way I would phrase that is if we're considering a smoking cessation process, and really it's a process, you know, I think we could probably do a whole interview just about what smoking cessation looks like, but it is a lifestyle change. And I think as a part of a fallback option or part of that lifestyle change, the temporary use of e-cigarettes is probably a reasonable consideration. And I think that's been endorsed by a lot of my colleagues in those associations and, you know, the American Thoracic Society and the American Lung Association as a short term fix. But it is really a short term thing for sure.

And when we're talking about younger adults who are looking at using this for a year in and year out, I think we're much less certain about what that's going to look like for those individuals even before we consider the entry point into combustible tobacco, which I think we can all agree is bad for you. And certainly, we have really good data to suggest that vaping in young people is really strongly associated with a transition to cigarette smoking later on. You know, there was just a study that was published by the University of Michigan in August of this year that showed a number that was even more startling than what we had seen before, and that is young people who are 15 to 17, by the time they fit into that 18 to 24 window, those young people were 22 times more likely to be tobacco smokers than individuals who are not vaping between the ages of 15 and 17. So, I don't mean to invoke Nancy Reagan for everybody, but this is a gateway drug. This is a gateway to other stuff for our patients, our children, our young adults, and we'd really like to avoid that.

Host: Certainly eye-opening indeed, because it punctuates the point you had just made prior, which is that vaping can be a way to get off cigarette smoking for older people, but it can lead to cigarette smoking for younger ones. So, how about this? Can both vaping as well as smoking cause lung cancer? Has it been around vaping long enough to know that at this point?

Kristopher McDonough, MD: Fantastic question. And again, I'd be remiss if I didn't point out that it's very clear that combustible tobacco use is associated with a variety of types of cancer, lung cancer, head and neck cancer, otherwise called throat cancer, kidney cancer, esophageal cancer, gastric cancer. I can kind of list as we go through that.

The data with vaping is less clear over the long term. You know, we are I'm fairly concerned about the solvents that are used in vaping liquids. And so, I don't want to get too wonky for our listeners and start talking about the differences between propylene glycol, which is a common solvent, and ethylene glycol, which is actually antifreeze, but also used as a solvent in some of these liquids and what those look like over time. We know that propylene glycol in the body can be metabolized to a number of downstream chemicals, which are associated with cancer. So, those are carcinogenic chemicals.

What is not clear to us, because we just don't have enough runway at this point in time, Is to understand what the long-term risks of those solvents are to people who have been using a vape pen or a Juul type device for decades upon decades, which is often what people do with smoking.

Host: Is the biggest misconception about vaping the fact that people tend to think it's less dangerous for your health than it really is?

Kristopher McDonough, MD: I think so. I think, I would even say take that a little bit further and say that the biggest misconception is that there is really no problem at all with vaping, right? I think that a lot of people don't just view it as a relativistic thing where they say, "Hey, look, tobacco use is really bad for me and vaping may be also bad, but less bad." And instead people say, "Well, tobacco use is bad for me, and vaping is not bad at all for me. So, why don't I just transition easily to this?" And that sort of leads to a number of decisions that might be made including, "Hey, I'm going to quit smoking, but I'm going to vape forever," which is clearly not the recommendation of either in our practice or, you know, sort of from the professional societies around the country and around the world.

You know, it's very clear that if we're going to transition to vaping as a way off of cigarettes, that transition needs to be a temporary one. We're not sort of advocating for people to smoke or to use a vape pen for five years or 10 years or 20 years. We're talking about over a period of maybe six to 18 months is what we're thinking about.

Host: Gotcha. And of the various means of vaping, is there one that's "preferred"?

Kristopher McDonough, MD: I don't think there's one that's preferred. I think there is definitely a set of conditions which are not preferred. And so, we have seen two pretty significant trends that can be associated with potential or very real harm with these vape pens. The first is some people will tend to alter their vape pen in a way that provides a warmer or hotter temperature of the solution and/or a larger puff of the aerosol that they're breathing in to the point where they may be getting sort of a toxic level of whatever it is that they breathe in. And so, I think anybody who's ever been a cigarette smoker is probably comfortable with a mild nicotine poisoning. So that, you know, sort of sensation of nausea that people get or a fast heart rate or a swimmy head, that's nicotine poison when it happens. And when people alter their vape pens, they can put themselves into a risk for that. And in fact, higher doses of nicotine that get into sort of the moderate and severe doses, severe levels of nicotine, which can be substantially more significant for them.

The other thing that we don't really understand when people adjust or alter their device that was made commercially and sold to them is how much of the toxic heavy metals they're getting in their aerosols. We know that the solder and the components of an e cigarette will tend to get into an aerosol and so we know that arsenic, tin, chromium, nickel, to name a few are all heavy metals that we found in these aerosol smokes. And the more you alter your vape pen, the more significant that can be. And so, basically, what I would say from the first part of this is we shouldn't be using non-commercially available vape pens or e-cigarettes in any circumstance. We should be using only the ones that are available because that alteration is going to expose you to risk.

I think the second issue becomes if you are inhaling non-nicotine related substances. So, when we talk a lot about vaping-related lung injury or vaping-induced lung injury, so called V-I-L-I, or VILI, that we saw. Most of the time we saw that was not in people who were using nicotine aerosols, but instead they were using THC-based aerosols, so THC being the psychoactive substance in marijuana. And in order to do that, the companies had to put THC in a lipid solvent. And so, people were breathing in really heavy doses of vitamin E, which is a pretty big lipid, and that was causing toxic injury to people's lungs. And so, what we see is that non-nicotine-related substances can also be a pretty significant risk when we're using these devices.

Host: Gotcha. A couple of other things for you. One being is it easier, generally speaking, of course, to quit smoking or vaping? And what's your best advice for those trying to quit vaping?

Kristopher McDonough, MD: Yeah. I don't know that I would say either is easy. You know, I like to acknowledge to my patients how very difficult it is to quit using nicotine. And really, that's the crux of this, right, is that nicotine is a psychoactive chemical. It goes into our brains and it makes us feel good, helps us deal with stress, helps us feel better after a meal. And there are a lot of different things that it goes with, right? I think cigarette smokers would tell you all of those things. And so, quitting using nicotine is really hard.

I think the first step then is to never start, right? And so if we can get to that point in time, and that's the message I think we send out to young people, is that quitting nicotine either with a vape or with a combustible tobacco product is going to be hard either way. It's unclear to me whether or not. quitting vaping if you've never been a cigarette smoker is relatively easy or not. I think it's hard. I do think that when you talk to a subset of adults who have been smoking for a long time though, they will tell you that it's easier to put down the vape pen than it was to put down the cigarettes. Again, because most of those people have been cigarette smokers for decades, right? They start smoking at 14, 15, 16 years old, sometimes much earlier, and they are quitting smoking at 50, 55, 65, so by that time they have been cigarette smokers for 50 years.

And so much of the tobacco smoke is not just the nicotine at that point in time, right? It is the taste of the cigarette. It is the action of using the cigarette going back and forth to your mouth. It is the smell of lighting it up. It is the social situation, right? Because most people who are cigarette smokers have friends or family who are also cigarette smokers, right? And so, I think most people would tell you that it's harder to give up that big sort of accumulation or conglomeration of things that come with a tobacco smoker or like a combustible tobacco product than it is to put down the vape pen later on. It's less clear to me if you've never been a cigarette smoker, how easy it is to quit vaping. I think it's probably fairly difficult.

Host: Gotcha. And then, finally, in summary here, Doctor, again, you mentioned in detail the differences between older versus younger people using vaping. That being said, what's the main thing people should consider before deciding whether to start vaping?

Kristopher McDonough, MD: If you're not a cigarette smoker now, please don't start vaping. That's the easiest thing to look at. If you are a cigarette smoker and you're considering quitting smoking, I think talk to your doctor and go through a set of parameters and expectations and develop a plan for smoking cessation. If part of your plan is the use of a vape pen or an e-cigarette that is a perfectly acceptable thing to do, understanding that it is a temporary situation when you're going to have to quit using your vape pen six months or 12 months after you quit using your cigarettes. And so, kind of going into it with eyes wide open is really, really important.

Host: Absolutely. Great advice indeed, folks. We trust you're now more familiar with vaping. Dr. Kristopher McDonough, thanks so much again.

Kristopher McDonough, MD: Thank you for having me.

Host: And for more information, please visit silvercross.org/lung-care/. Again, silvercross.org/lung-care/. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for listening to Silver Cross Hospital's IMatter Health Podcast.