Jeannie Cox currently enjoys a flavor called Coffee & Cream when she vapes. She’s also fond of White Lotus, which tastes “kind of fruity.”
She buys those nicotine-containing liquids, along with her other e-cigarette supplies, at Mountain Oak Vapors in Chattanooga, Tennessee, where she lives. A retired secretary in her 70s, she’s often the oldest customer in the shop.
Not that she cares. What matters is that after ignoring decades of doctors’ warnings and smoking two packs a day, she hasn’t lit up a conventional cigarette in four years and four months.
“Not one cigarette,” she said. “Vaping took its place.”
Like Cox, some smokers have been able to stop smoking by switching to e-cigarettes, and many are trying. A recent study by the Centers for Disease Control and Prevention found that more smokers now attempt to quit by using e-cigarettes as a partial or total substitute for cigarettes than by using nicotine gum or lozenges, prescription medications or several other more established methods.
Her success is what researchers disdainfully call “anecdotal evidence,” however. There’s “no conclusive evidence” that e-cigarettes help people stop smoking long-term, said Brian King, deputy director of the CDC’s Office of Smoking and Health.
At the moment, therefore, neither the CDC, the Food and Drug Administration nor the U.S. Preventive Services Task Force has approved or recommended e-cigarettes for smoking cessation. In fact, the rise of e-cigarettes has generated contentious debate among public health officials and advocates.
But while the proportion of Americans who smoke continues to decrease — down to 15.1 percent in 2015 — the decline has stalled among older adults.
People older than 65 have always been less likely to smoke than adults in general, in part because premature death means fewer smokers survive to older ages. In 1965, when the CDC started tracking smoking rates, 18.3 percent of older adults were smokers.
It took 20-plus years for the proportion to fall below 15 percent.
But over the last six years, that percentage has plateaued, bouncing between 8 and 9 percent. That still leaves millions of older smokers who probably know they should quit, and may want to, but haven’t.
Might switching to vaping improve their health, even if they never become nicotine-free?
“Vaping is clearly less harmful than regular cigarettes,” said Dr. Steven Schroeder, who directs the Smoking Cessation Leadership Center at the University of California, San Francisco, and is a co-author of a recent JAMA article reviewing tobacco control developments.
Some studies have estimated that e-cigarettes confer at least a two-thirds reduction in health risks, compared with smoking.
Nicotine, Schroeder pointed out, isn’t the primary culprit in the long list of smoking-related diseases. It’s the addictive ingredient that keeps smokers lighting up, but the thousands of other chemicals in combustible cigarettes, among them 70 known carcinogens, do most of the damage.
“If you could get nicotine in a safer form, like an FDA-approved medication, even for the rest of your life, you’d be in far better shape,” said David Abrams, a clinical psychologist at New York University who researches nicotine and smoking.
This argument, known as harm reduction, recognizes that the best course for older smokers is to quit both cigarettes and e-cigarettes — especially since questions remain about the latter’s safety, for users and for those inhaling secondhand vapor.
But harm reduction proponents like Abrams maintain that given the difficulty of quitting altogether, vaping could provide a reasonable alternative. “Any smoker, especially an older smoker, who isn’t thinking about switching is doing himself a major disservice,” he said.
Cox wasn’t actually thinking about switching. She had loved smoking ever since she was a teenager sneaking Marlboros, and although she had developed a nighttime cough, she wasn’t trying to quit.
But she’d planned a fall visit to her nonsmoking children in Alaska in 2013, and standing outside their home to smoke sounded unappealingly chilly. Cox did some online research, tried several flavors at Mountain Oak and bought a starter kit.
“I’m not quitting smoking; I’m just trying this newfangled thing,” she told herself. “Three days later, I realized I hadn’t smoked a cigarette in three days. I thought, ‘This is working out kind of nice. Quitting is not supposed to be this easy.’”
Usually, it’s not. Although older smokers don’t seem to have a harder time than others, stopping cigarettes cold-turkey only rarely works.
Would-be quitters can greatly increase their odds of success by using FDA-approved nicotine replacement products, or a prescription drug like Chantix, and by seeking support from smoking cessation counselors or telephone quit lines like 1-800-NOBUTTS.
“We know what works,” said King of the CDC. “We have 50 years of science showing what works.” Still, smokers make an average 15 attempts before they become ex-smokers.
The fear that they’ll stop trying to go nicotine-free, and vape instead, is one reason the CDC and most public health groups don’t embrace e-cigarettes.
In fact, the CDC reports that most smokers don’t entirely switch; they become “dual users” who continue to smoke while vaping. Because even a few conventional cigarettes daily increase the risks of mortality and cardiovascular disease, “you’ll still get an adverse health effect,” King said.
Further, the CDC takes a broad view of what improves public health, and it worries about growing e-cigarette use by adolescents (though conventional smoking has declined in that age group), even if the products might help others stop.
Longtime suspicion of Big Tobacco plays a role in the e-cigarette controversy, too, as the industry muscles into a field now populated by hundreds of small vapor companies.
The FDA had planned to begin regulating e-cigarettes next August, prompting an outcry that small manufacturers unable to afford the hefty costs of applying for approval would simply shut down, leaving the field to the likes of Philip Morris.
The agency has since pushed e-cigarette regulation back to 2022. “A delay of execution,” said Gregory Conley of the American Vaping Association. For now, the industry can’t advertise vaping products as safer than cigarettes or even as smoke-free.
The industry has not particularly targeted older smokers, Conley said, possibly seeing them as set in their purchasing habits, and unwilling to spend time in vape shops experimenting with vaporizers and liquids to find a satisfying substitute for cigarettes (and a cheaper one, after the initial equipment purchase).
But older smokers also have a greater need to give up cigarettes. Not only can quitting extend their lives, but it can ward off many of the debilitating effects of heart disease, diabetes and other chronic disorders. Nonsmokers respond better to surgery and chemotherapy, Schroeder noted, and older adults often face one or both.
Cox wasn’t feeling ill, apart from that cough, when she switched to a vaporizer and unintentionally stopped smoking. But she felt better afterward.
“I could breathe easier,” she said. “I was no longer coughing. I could sleep longer. I got happier.”