What’s the key to ending vaping? Not following smoking’s roadmap

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Sep 24, 2019

If you’ve read the news recently, you’ve seen a harrowing trend: at least six people in the United States have died from vaping-related lung illness, with hundreds more cases of illness currently reported. To add to the concern: teenage vaping is far outpacing adult vaping, with teens sixteen times more likely to vape than adults aged 25-34. And the rate of teen vape use is climbing. 

Vaping is “the act of inhaling and exhaling the aerosol, often referred to as vapor, which is produced by an e-cigarette or similar device”. It’s marketed as “cleaner” than traditional cigarettes and has a less distinctive odor and no smoke. However, e-cigarettes still contain nicotine, and create significant health risks. A single Juul “pod,” for instance, contains just as much nicotine as an entire pack of cigarettes.

Given the severity of the issue, advocacy groups are calling for action to limit e-cigarette use, by raising the age for sale of “tobacco products” or other methods. Earlier this month, the White House said it would ban the sale of flavored e-cigarettes, and just last week Walmart said they would stop selling the devices. This begs the question: will efforts like these be effective in curbing teen vaping, and if not, what can be done?

To answer this question, let’s take a step back. Before e-cigarettes, there were traditional cigarettes. Teenagers have traditionally turned to smoking, despite its health risks, for a number of reasons. Functionally, smoking is seen as a “quick and easy” way to reduce stress and “feel good”. In certain groups smoking makes it easier to socialize with others, and appear cool. Youth especially have historically found it a way to look mature to their peers, as well as a way to rebel. 

Yet campaigns to curb teen smoking have been extremely effective, and are a huge public health victory. In the past 21 years, teen smoking has decreased from 24.6% to 3.6%. Why?

Understanding the forces that drive consumer choices

To illustrate why efforts to curtail cigarette use among teens have been effective, we can look to the Forces of Progress framework, which outlines the different forces acting upon someone as they consider a behavior change. There are two types of forces: those compelling change (or adoption of a new solution) and those opposing change. 

The Forces Compelling Change include the “push of the situation”—essentially the frustration or problem someone’s trying to solve—and the “pull of the new idea”—whatever it is that makes a solution enticing. 

In 1998 the tobacco Master Settlement Agreement prohibited tobacco companies from interfering with research on the dangers of smoking. Public awareness campaigns have since been able to push teens towards quitting by exposing the dangers and health risks, and by demonstrating how teens are often exploited by the industry. Over time, these campaigns have made smoking appear less attractive and even “dirty”. These efforts have been amplified by the fact that many smokers feel an intrinsic pull to quit, whether it’s to excel in sports, or improve one’s social life now that smoking is less in vogue. 

There are also the Forces Opposing Change. These include the  “habits of the present”—which may be driven by comfort with familiar practices or resignation to living with a problem—and “anxiety of new solutions”—which accompany even the most compelling solutions.

Policymakers in various states have worked to make smoking harder to keep up by raising the prices of cigarettes, increasing taxes, and even raising the age that one can legally purchase tobacco products. Further, laws have been put into place to limit where people are allowed to smoke, and where and how smoking can be advertised. To ease the anxiety of quitting, pharmaceutical companies have introduced products so smokers don’t have to quit cold turkey. Healthcare providers and hospitals offer smoking cessation programs for those in need of additional support, and the CDC provides an app, text alerts, and a social media plan to provide tips and social support for those quitting. 

In short, efforts to curb teen smoking have been effective because the forces compelling teens to quit have been stronger than those discouraging them from doing so.

A new problem, a new solution

One might assume that policymakers can simply piggyback off of their success in reducing smoking now that e-cigarettes, like Juul, have entered the market. Many teens are drawn to vaping for the same reasons they’ve traditionally been drawn to smoking—there’s the perception it looks cool, it’s a way to rebel, and it helps them de-stress and socialize. But now there is less motivation to quit.

The Forces Compelling Change are not strong enough. There is no push to quit because vaping is misunderstood to be less dangerous; a 2016 study showed that the majority of young e-cigarette users believed they were only vaping flavoring, not nicotine. E-cigarettes are also considered less “dirty” compared to traditional cigarettes, so there is no push from a personal hygiene standpoint. And while the pull—the desire to live a healthy life—may be the same, not recognizing vaping as dangerous means that quitting may not be a part of that desire.  

At the same time, the Forces Opposing Change are stronger for e-cigarettes. For teens in particular, vaping is encouraged in part by the fact that e-cigarettes are smaller than cigarettes, making them easier to transport and conceal. Since vapor is exhaled instead of smoke, they can be used anywhere, including indoor locations where smoking is typically prohibited. They’re also far easier for youth to access, and more affordable than cigarettes. Interestingly teens do not appear to experience major anxiety around quitting, but that’s likely because most aren’t considering doing so in the first place, as evidenced by the fact that teen vape use is rising.

When it comes to teen vaping, it’s clear the forces discouraging users to quit far outweigh those compelling them to quit.

Efforts that decreased teen smoking will not be enough to curtail an e-cigarette epidemic. Looking at the Forces of Progress, factors compelling teens to stop vaping are not as strong as those that have compelled teens to ditch cigarettes. Even banning flavors, which addresses one of the biggest draws, doesn’t change the fact that e-cigarettes are easier to use and believed to be less dangerous. In order to dramatically reduce e-cigarette use in teens, policymakers and advocates need to address two factors: the fact that teens don’t feel incentivized to quit, and the ease with which they’re able to keep up the deadly habit.

Jessica is a research associate at the Clayton Christensen Institute for Disruptive Innovation, where she focuses on business model innovation in healthcare, including new approaches to population health management and person-centered care delivery.