E-cigarettes and the Paradox of Technology
Technology is a paradoxical thing. Human beings are tool-making animals, and have always looked to their abilities to craft things from the natural world to solve problems of living. Most of our knowledge of our early ancestors are reflected in the tools and technologies they have left behind. We use technologies to solve the problems of living, and so the things we create -arrowheads, cooking utensils, bone flutes, jewelry – can teach us about a culture’s priorities, needs, aesthetics, and resources.
All technological solutions, however, also generate problems. The first arrowheads changed us into hunter-gatherers; the first plows into sedentary farmers. The car allowed manufacturing to leave the inner city and move workers to suburban factories; the result was a period where our major American cities were bereft and deteriorating, until we reinvented them as social and economic centers. Technologies always bring change and challenge which themselves create new kinds of problems. We then try and create new technologies to solve the problems created by older technologies, and those new technologies themselves then create new problems that we solve with even newer technologies. It is an endless cycle, and results in the paradox that we always seem have too much technology and not enough technology at the same time.
The problem is only magnified when technology reaches the kind of power and sophistication that we see today. The computer changed the way we shop, interact, do our work and get our news and entertainment. Cell phones changed how we communicate (or fail to communicate), how children play and socialize, how we find our way around through GPS and obtain our tickets, taxis, and texts.
If societies use technologies to solve their thorniest problems, it is not surprising that almost every society throughout history has used its best and most sophisticated technologies to address its problems of sickness and suffering, disease and death. Illness is disruptive (and existentially challenging). The cost of illness to the state is staggering, with time off the job and the needs to cater to illness are in the billions. So it is not surprising that our enormous medical-industrial complex is among our most advanced scientifically and that biotechnology is a symbol of the most challenging and complex uses of our vast scientific knowledge.
But, if all new technologies also create new problems, our medical miracles themselves generate new problems to be solved. We are well acquainted with many of them: the advances in life support generated a new class of patients that would have died in earlier eras leading to complex debates about end-of-life care, removal from respiration, euthanasia, etc. Transplant technology led to the first universal scarcity problem, where distribution of organs was centralized to fairly ration a life-saving resource; now, organized groups are pressing to allow the sale of organs. New diagnostics have resulted in questions of how to treat conditions like ductal carcinoma in situ or prostate cancer, where the prudent thing might be not to treat them at all. And while biotechnology has brought in new treatments for cancer and conditions like hepatitis C, they come with price tags that challenge both our health care system and means for fair rationing of expensive treatments.
Let’s take a recent, if relatively small, example: news from a number of studies demonstrates the difficult process of assessing and using one relatively new technology: electronic cigarettes (“E-cigarettes”). E-cigarettes have been around for over 30 years, but have recently been promoted as a way to help people stop smoking. The idea was to use e-cigarettes as a less dangerous way to satisfy the smoking craving, while allowing a phased transition to quitting altogether.
Today, over 12% of the American adult population have at least tried an e-cigarette, and about 4% percent of Americans use e-cigarettes regularly. E-cigarettes are now the most commonly used form of tobacco by youth in the U.S, growing an astounding 900% among high school students from 2011 to 2015. Over 20% of young adults, 18-24, have tried them. Global e-cigarette sales amount to around $5 billion a year.
First, are e-cigarettes better than tobacco? The results are mixed. A study from the National Academies of Sciences, Engineering, and Medicine just reviewed over 800 studies and published a comprehensive report investigating the effects of electronic cigarettes. While the report found that e-cigarettes have their own potentially carcinogenic ingredients, when used by previous tobacco smokers they do reduce exposure to many toxins and carcinogens, though not necessarily nicotine. E-cigarettes may reduce risk of respiratory disease like COPD over tobacco smoking, though that is not definitive.
And e-cigarettes may in fact help people stop smoking cigarettes. A study from the British Medical Journal of over 160,000 people over 15 years found that smokers who used e-cigarettes tried to quit smoking more often and succeeded more often than those who did not use them, and more people have been trying e-cigarettes, leading to an overall decline in smoking. So all in all, e-cigarettes seem a positive technological tool to address smoking cessation.
However, there is a growing downside. A study in JAMA Pediatrics surveyed more than 10,000 adolescents aged 12 to 17 from across the United States who said they had never smoked cigarettes. The study followed up with participants a year later. Teens who had used e-cigarettes or other non-cigarette tobacco were twice as likely to have smoked cigarettes at the one-year follow up. The finding is worrisome because, according to the CDC, use of e-cigarettes by middle and high school students nearly tripled from 2013 to 2014, creating a “vape culture” among adolescents. E-cigarettes seem more harmless, are easier to use (no fire is necessary) and easier to conceal (they look like pens and create less detectable smell). They can be used for tobacco, marijuana, and other chemicals; vaping becomes a creative exercise, where different flavor combinations and fashionable devices are attractive to teens. Teens report finding it “cool” and an activity that is done in groups and at parties. Vaping tricks get millions of hits on YouTube videos. People younger than 18 can easily order e-cigarettes online, and though the FDA has begun a process of cracking down and restricting e-cigarette sales, the e-cigarette industry is fighting back. In some countries, minors can buy e-cigarettes as long as they do not contain nicotine, but then it is usually simple for them to find refills for the vape pen that do contain the chemical.
So, technology has created a new tool for smoking cessation and a new enticement to become a smoker. A way to ingest chemicals that, in some cases, becomes a substitute for smoking instead of a tool in its cessation. A less harmful way to use nicotine that has its own harms. A technology that sidesteps the years of efforts to make smoking uncool by making it cool once again.
E-cigarettes can be a useful new technology in certain cases, but it has significant risks and challenges. And so, once again, we have to think about our relationship to technological access: How do we best control this new technology with its positives and negatives? Do we encourage a slightly better alternative than tobacco, knowing it may grow into an equally challenging social problem? We seem to need to relearn again and again that technologies rarely solve a problem simply and without collateral effects. We live and change with our technologies, and need to be ever vigilant about their benefits and risks.
Schoenborn, CA, Gindi, RM. Electronic Cigarette Use Among Adults: United States, 2014. Centers for Disease Control, https://www.cdc.gov/nchs/data/databriefs/db217.pdf
Stratton K, Kwan LY, Eaton DL (editors). Public Health Consequences of E-Cigarettes. National Academies of Science Consensus Study Report, The National Academies Press. 2018. https://www.nap.edu/catalog/24952/public-health-consequences-of-e-cigarettes
Watkins SL, Glantz SA, Chaffee BW. Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015. JAMA Pediatr. Published online January 02, 2018. doi:10.1001/jamapediatrics.2017.4173
Zhu S-H, Zhuang YL, Wong S, Cummins SE, Tedeschi GJ. E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys. BMJ 2017; 358.