The State of Cigarette Alternatives

By Russell Herring, DNP, FNP-BC, CSCS

“Mad vapes, bro”.

I’m at a stoplight again, and the car next to me is billowing vapor, like a steam-powered locomotive.

I think it looks a little ridiculous, but some “vape enthusiasts” intentionally modify their devices to emit the maximum cloud possible, so I feel an obligation to compliment them on their achievement.

I wouldn’t recommend this approach to others, but I’ve always been a slow learner with a big mouth.

I suspect elucidating whether vaporized nicotine predates vaporized marijuana would be a challenging research question. Perhaps an equally difficult question would be determining whether the first electronic-cigarette was intended as a “healthy” (healthier) alternative to smoking tobacco, or simply as an alternative method of consuming the drug, without respect for whether it’s healthy or not (please note that it is not healthy). I can say with certainty, that my first personal exposure to electronic cigarettes was about 10 years ago, via my mother-in-law, and that she was immediately very brazen about using them in confined spaces with the rest of us because of how “harmless” her new e-cig was.

I raised objection. If I can see the vapor, then I’m smoking the same stuff you are.

There was a period of friction.

Fast forward 10 years to Great Falls Clinic Northwest and I’m seeing young people who’ve started consuming nicotine via vaping and electronic cigarettes. I see older patients who are dependent on oxygen after decades of heavy cigarette use. There is heavy coverage in the national press about electronic-cigarette and vaping-associated lung injury (EVALI).

I’ve found there are things you can never assume about other humans. I’ve been surprised by the diversity of patients who use recreational marijuana. I’ve been caught off guard by the age of some of the patients who’ve needed the “safer sex” talk. You can’t assume someone isn’t a closet smoker, drinker or user. I don’t judge, I just ask the questions and work as constructively as possible with the responses. Several older folks have surprised me with their vape habits.

Discussions about vaping and e-cigarette use have become extremely important in the exam room.

“How long have you had this cough? Are you short of breath? Are you short of breath at rest or only with activity? Do you smoke? Do you vape? Do you use electronic cigarettes? From where do you purchase your vape or e-cigarette products?”

I can confirm that high school age patients have commented, in late 2018, on how easy it was to obtain e-cigs. An upperclassman could buy several at once, and there was no tracking, or limitations on purchase quantity. I’m reminded that one of the reasons the drinking age was raised to 21 was that it placed the drinking age firmly outside the high school.

The Centers for Disease Control and Prevention have been frantically trying to determine the cause of EVALI. Cases of this condition have been found in all 50 states, and include both THC and nicotine-containing formulations ( The CDC has arrived at vitamin E acetate as the most likely culprit in the development of EVALI (ibid). When consumed orally, vitamin E is an important antioxidant and takes part in enzymatic activities within the body. However, when added to vape or e-cigarette juice as a thickening agent, it can cause damage to the fragile tissues of the lower respiratory tract (ibid). EVALI has symptoms ranging from mild cough to death from respiratory demise (Chatham-Stephens, et al. 2019). The condition has affected patients of all ages and has been seen with respiratory symptoms (85%), gastrointestinal symptoms (57%) and more broad-ranging constitutional symptoms such as fever, chills and weight loss (76%) (ibid).

I have to preface the following advice as pertaining exclusively to those who already smoke. If you do not smoke, then weaning yourself into a nicotine habit by vaping or using electronic-cigarettes is foolish, in the absolute extreme – even if the product comes in an exciting cotton candy flavor and makes you look like a locomotive at stop lights. Introducing an addictive substance into your body, which has absolutely no recognized medical benefits, is dense – again in the absolute extreme. There is no upside to nicotine addiction.

Now I sound like your father.

Despite all of the negative press surrounding vaping and electronic-cigarette use, the cold, hard, truth is that these products, when purchased from a reputable source and manufacturer, are safer than smoking tobacco, for non-pregnant adults ( Nicotine is technically contraindicated if mammal (you are a mammal), but particularly if a you’re a pregnant mammal. Electronic cigarettes are especially not safe, per the CDC, for pregnant women, young adults, youth, and adults who currently do not smoke.

Nicotine is still a carcinogen.

The CDC does not currently recognize any electronic cannabis product as safe (ibid).

It is a game of equivalences. If you do not smoke, then the only safe and sane option is to keep it that way. If you currently grind up a shrub, set it on fire, and inhale the combusted result into some of the most fragile of body tissues, then using a vaporized product is a better option (ibid). I’ve already noticed several producers that are advertising their lack of vitamin E acetate, so this might be a good thing to look for, if you are a smoker who needs to find a (relatively) healthier option. I have patients who’ve failed pharmacologic smoking cessation aids and are still smoking, even though they’re now on oxygen. We’ve talked about alternatives – anything that might reduce the volume of dried up shrubbery they’re inhaling into their already seriously damaged lungs. This has included electronic cigarettes, nicotine pouches and learning to spin pencils so they have something to do with their hands while their brains think they should be holding a cigarette.

Smoking is bad for you. Be it cigarettes, cigars, pipes, vapes, electronic cigarettes, hookahs or something I’ve never heard of – consuming drugs with your lungs is a bad idea. However, if you are currently a smoker searching for any way to stop, or someone who can’t seem to stop despite trying everything, e-cigs obtained from an actual store, and which don’t contain vitamin E acetate, are technically a safer alternative. Not a safe alternative, a safer alternative.

Remember, this is a game of equivalences.

Visit your healthcare provider. Ask about ways to stop or cut back. If there is an interval of safe vs safer alternatives, I get it.

Addiction is real, please accept help.

Russell Herring
Russell Herring, DNP

About Russell Herring, DNP, FNP-BC, CSCS

Russell R. Herring, DNP, joined the Great Falls Clinic in 2018 and is among the newer healthcare providers and prescribers in the State of Montana. He works alongside Dr. David Engbrecht and Dr. Carey Welsh in Family Medicine at the Great Falls Clinic Northwest location. Russell specializes in diagnostic, preventive, and therapeutic healthcare and treatment plans for acute and chronic illness, and in education and guidance of patients regarding disease prevention and health promotion. He is currently accepting new patients at the Northwest Clinic, 1600 Division Road, Great Falls. For more information or to schedule an appointment, please call 406-268-1600.