n 2014, the Oxford English Dictionary christened "vape" the Word of the Year. The designation was a tribute to the impressive rise of the electronic cigarette, a battery-powered device that heats a flavored solution containing nicotine and converts it into an inhalable, or "vape-able," aerosol. By the close of 2013, six years after e-cigarettes became available in the United States, sales had surpassed $1 billion, prompting financial analysts to proclaim them a threat to cigarette sales. Observers hailed e-cigarettes as "among the most significant public-health innovations of modern times" and a "disruptive technology" poised to "revolutionize" public health.
Invented for smokers who cannot or will not quit, e-cigarettes do not burn tobacco, and therefore emit a mere fraction of the carcinogens and hazardous gases than do conventional cigarettes. This means vaping is substantially less harmful than smoking, which causes roughly 480,000 American deaths each year. Today, roughly 11 million adults use electronic cigarettes. With the exception of quitting cold-turkey, vaping is not only the most popular strategy but the most effective.
In other welcome news, early fears that e-cigarettes would "re-normalize" smoking among adults and lead teens to take up smoking have not materialized. And if over the next 10 years the nation's smokers switched to vaping, according to conservative demographic estimates, more than 1.6 million premature deaths could be averted by 2100. In short, e-cigarettes offered a potent alternative to cigarettes, which Stanford historian of science Robert Procter has aptly called "the deadliest artifact in the history of human civilization."
Just five years later, in November 2019, several hundred vapers assembled on the White House ellipse. Pink clouds redolent of strawberry, cinnamon, and peach hung low in the air. "We vape, we vote," the vapers chanted. "Flavors Save Lives" read their placards. The messages were aimed at President Trump who had announced weeks earlier that he planned to ban e-cigarette flavors. His move was just a part of a larger cultural and political campaign against vaping that shifted into high gear last fall. The drive included congressional hearings with titles like "E-cigarettes: An Emerging Threat to Public Health." Angry parents marched in protest. The American Medical Association urged a flat-out ban on vaping. A smokers' helpline run out of a California state university launched a "quit vaping" program. Meanwhile, the market value of tobacco companies — which had declined by roughly half since around 2017 — started to rebound, likely due to confidence that vaping would not be a serious long-term competitor with the more lucrative combustible cigarette.
In a mere half a decade, the e-cigarette went from being lauded as a possible salvation from smoking to being denounced as a public-health disaster. How did this happen? How could local public-health officials in some cities facilitate their removal from store shelves while leaving deadly Marlboros and Newports for sale, waiting to fill the nicotine void? The answer involves some of the usual culprits — tone-deaf marketing by manufacturers, flawed regulation by government, and scare-mongering by the media. But something more troubling lies at the heart of the story: an extraordinary lack of intellectual integrity in a prominent sector of the public-health community.
FROM HON LIK TO JUUL
A Chinese pharmacist named Hon Lik invented the first commercially successful e-cigarette, spurred by his own difficulty quitting cigarettes and by his father's lung cancer, which followed a lifetime of smoking. Hon's disposable device looked like a metallic cigarette, featuring a red light at the end that glowed when a puff was drawn. He named his company Ruyan, meaning "almost smoke." The disposable, pre-filled devices were brought to market in Beijing in 2003 and appeared in U.S. retail outlets in 2007. Domestic versions of these "first generation" e-cigarettes, also called cig-alikes, soon followed. The devices did not appeal to heavy smokers, however, because they delivered a weak dose of nicotine.
A second-generation e-cigarette with increased battery power quickly emerged. Users pressed a button on a non-disposable pen-like apparatus to heat the nicotine solution and inhale the aerosol. Soon, a third generation of devices ("mods") with even more powerful batteries came on the scene. Users' signatures are the large, billowy clouds of vapor they blow. The palm-held devices have a mouthpiece containing the heating coil and a small receptacle, or "tank," for e-liquid attached to a squarish body housing the rechargeable batteries. Second- and third-generation devices are called "open systems" because the user refills the tank. Vapers can mix their own e-liquids using a variety of flavors and strengths of nicotine. Enthusiasts customized batteries and coils in their own garages and workshops, and eventually opened vape shops and lounges. They posted instructional YouTube videos for vapers who wanted to modify their own apparatuses.
The industry grew from the bottom-up, propelled by consumers' word of mouth, as the vape shop became the center of vape culture. The typical owner is a former smoker who swears he owes his life to vaping and wants other smokers to convert. Proprietors help customers choose the devices, nicotine content, and flavors best for them. As one observer put it, vape shops are nothing less than "smoking cessation clinics." Another described the shop and vape lounge "as a kind of neighborhood bar, with each new customer, there was a familiar greeting, an exchange of pleasantries, and the sense that it was one big smoky, weird-but-not-unpleasant-smelling family, united in the fact that they'd all quit cigarettes and now fear future government regulations would destroy their newfound habit and hobby." Vaping has become an identity, complete with its own festivals; the first Vapefest took place in Fredericksburg, Virginia, in 2010.
The fourth generation e-cigarette arrived in 2015, most notably in the form of JUUL, made by a company of the same name. The device resembles a sleek, four-inch thumb drive, and its battery can be recharged by plugging it into any USB port. JUUL uses a "pod-based" system; its e-liquid comes in small, sealed, replaceable units. A pack-a-day smoker trying to quit cigarettes would consume about a pod per day, as each JUUL puff is roughly equivalent to or slightly less than a cigarette puff. Originally available in eight flavors, including mango and cucumber, JUUL delivers a strong hit of nicotine to the brain and a punch to the back of the throat that smokers find particularly satisfying. JUUL comes closest to separating nicotine, a fairly benign substance, from the dangers of a delivery system (the cigarette) in a manner that many smokers find attractive. Sales rocketed six-fold to $1.3 billion from 2017 to 2018. Meanwhile, JUUL copycats began flooding the market in 2017.
All four generations of e-cigarette have been inspired by the philosophy of "harm reduction," which is the imperative to minimize hazard in people who, rather than desist, will continue to engage in risky behaviors. The virtue of vaping is that it uncouples deadly smoke from nicotine, which, contrary to common impression, has no appreciable role in causing cancer. Classic harm-reduction strategies include the distribution of condoms to teens and clean needles to injection-drug users, and pre-exposure prophylactic medication and safe-sex information for populations at risk for HIV/AIDS. As a safer alternative for smokers, vaping is to nicotine addicts what methadone is to opioid addicts. Many smokers find vaping more appealing than traditional nicotine gums and patches because of its cigarette-like attributes, such as the ritualistic handling of an object, the social dimension of use, the physical sensation of inhalation, and the hit of nicotine that it delivers. Yet many of the same public-health institutions that promote harm-reduction strategies to users of other drugs, are reluctant, if not hostile, to extending the same forbearance to smokers. This paradox is rooted in the anti-tobacco movement, which has, along with irresponsible actions by public-health institutions, derailed the vaping revolution.