Drug Delivery Systems

should vaping be discouraged?

Nicotine patches are currently marketed as a cure for smoking. What they actually are, so far as I can tell, is an alternative delivery system for the same drug. …

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This may be an early and interesting example of an alternative approach to the problems associated with both legal and illegal drugs. The conventional solution is to stop people from using drugs. The alternative is to find ways of providing the effects drug users want while minimizing undesirable side effects, on themselves and others. (Ideas, August 21, 2006)

Rereading my old blog I came across something I wrote twenty years ago. How does my speculation look twenty years later?

Nicotine is still, so far as I know, the only drug for which alternative forms of delivery are common, perhaps because it was the only drug for which most of the danger came from the delivery medium. Nicotine patches and other delivery systems exist but vaping, a technology invented only a few years before I wrote and not then common, is the main alternative to smoking in the US at present.

As of 2024-2025, about 6.9% of U.S. adults use e-cigarettes, with usage highest among young adults (15% of those 18–34). … . Cigarette smoking, though declining, remains at 9.9% for adults… (AI Overview)

Looking for data on risks, I found a page by the FDA. It conceded that vaping is less dangerous than smoking, but :

While e-cigarettes can generally be a lower-risk alternative for adults who smoke cigarettes, the use of e-cigarettes is not risk-free. These products deliver harmful chemicals and contain nicotine, which is highly addictive. Moreover, given the harmful chemicals found in e-cigarettes, further high-quality research on both short- and long-term health outcomes is needed. (The Relative Risks of Tobacco Products)

Despite its title, the page contains no information about how large those risks are, just that they exist. The same is true of the CDC page Health Effects of Vaping. Both pages refer to a variety of risks from vaping but no numbers. The American Heart Association in its article on nicotine pouches, another delivery system, concedes that

no data are available on their cardiovascular or health risks. (Review Article)

Both the FDA and CDC pages make a point of the fact that vaping is not safe while conceding that it is less bad than smoking. That, plus the absence of numbers, made me suspect that they might be exaggerating how dangerous vaping is. If vaping is only a tenth as dangerous as smoking, if the benefit from getting one smoker to switch to vaping is as large as the benefit from persuading nine vapers to quit entirely, putting the emphasis on how unsafe vaping is instead of on how much safer it is than smoking might be counterproductive.

The FDA and CDC, and others, might still do it. I have observed, in other contexts, people reluctant to say anything good about something — smoking, alcohol, ice cream — that everyone knows is bad.

I found more information, and numbers, in an article from Johns Hopkins. It reported on health outcomes for 249,190 individuals, classified as nonsmokers, smokers, vapers, or both followed for 3.7–3.9 years. The results are shown below:

All five health conditions are made significantly worse by smoking, only COPD by vaping.

I found a CDC page with figures on mortality from different effects of smoking. Using that and the Johns Hopkins data I can calculate what mortality from vaping would be if as many people vaped as smoke and take the ratio of that to actual mortality from smoking as an estimate of the relative risk of the two delivery modes.

The figure for mortality from COPD was 100,600. Assuming that a third the effect, as per the Johns Hopkins data, yields a third the mortality, that gives a mortality from vaping of 33,533. Total mortality from smoking (CDC) is 480,317.¹ So the data I have imply that a smoker who switches to vaping eliminates more than ninety percent of the problem.

That assumes that COPD is the only major source of mortality from vaping. The one important source of mortality from smoking not covered in the Johns Hopkins Study is cancer. It is easy to find statistics for cancer deaths from smoking but not for vaping. Looking for them, I found:

Some chemicals present in e-cigarette aerosols, such as formaldehyde and acrolein, can cause DNA damage and mutagenesis that can lead to cancer. Long-term exposure to e-cigarette aerosols could increase the risk of cancer and adverse reproductive outcomes; however, given that studies varied, additional research is needed. (Truth Initiative)

I translate that and similar passages on other pages as “vaping could cause cancer but there is no evidence that it does.” The Wikipedia page on nicotine makes that explicit, for the drug if not the delivery system:

Contrary to popular belief, nicotine itself does not cause cancer in humans, although it is unclear whether it functions as a tumor promoter as of 2012. A 2018 report by the US National Academies of Sciences, Engineering, and Medicine concludes, “⁠[w]hile it is biologically plausible that nicotine can act as a tumor promoter, the existing body of evidence indicates this is unlikely to translate into increased risk of human cancer.” (Wikipedia)

I conclude that persuading people who smoke to switch to vaping does almost as much good as persuading them to quit entirely, hence that for anti-smoking groups to emphasize the dangers of vaping, as they do, is probably a mistake if their objective is to reduce the number of smokers.

Warning about the risks of vaping does, however, discourage non-smokers from trying it, so there remains the question of whether vaping, considered on its own merits, it is a bad thing. It has at least one undesirable effect,² the increased rate of COPD, but smokers report and research supports a variety of desirable effects from smoking, presumably due to the nicotine and so available by vaping as well.

In humans, nicotine acts primarily as a stimulant by binding to and activating nicotinic acetylcholine receptors (nAChRs) in the central nervous system and peripheral tissues. This results in the release of neurotransmitters such as dopamine, acetylcholine, and norepinephrine, producing effects including increased alertness, reduced anxiety, and mild euphoria.

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A 2010 meta-analysis of 41 double-blind, placebo-controlled studies concluded that nicotine or smoking had significant positive effects on aspects of fine motor abilities, alerting and orienting attention, and episodic and working memory. (Wikipedia)

A further question is whether, if the objective is the positive effect of nicotine, vaping is the best way of getting them. That brings us back to the issue of alternative delivery systems.

Including patches.

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1. That includes 41,284 from second-hand smoke, which I am dubious about but for the purposes of this calculation include.

2. There are also reports of undesirable effects of nicotine on specific populations of users such as adolescents and pregnant women.