When 19 high school students and I took our seats at the Med School 101 class called "E-cigarettes, vape pens, e-hookah: What you need to know," we weren't entirely sure what to expect. At this annual event, during which Bay Area teens get a taste of life at Stanford's School of Medicine, all of the classes are a little unconventional and a lot of fun. But I don't think any of us expected that a course on e-cigarettes and vaping would be anything other than a lecture on the dangers of nicotine.
We were pleasantly surprised.
The class was led by Judith "Jodi" Prochaska, PhD, MPH, and Robert Jackler, MD — two scholars whose research often reveals startling insights into the behavior of the tobacco industry. Prochaska, whose work focuses on ways to help people change habits related to smoking, physical activity and eating, was among the first to create a stop-smoking program for people with psychiatric disorders, a revolutionary idea that was unheard of not long ago. Jackler's work, meanwhile, includes studies on the impact of tobacco advertising, marketing and promotion. One of his studies uncovered a cadre of otolaryngologists — all hired by the tobacco industry — that repeatedly testified that heavy smoking didn't cause cancer in cases of dying patients suing for damages.
Prochaska began the class by asking the students to list words they associate with e-cigarettes and vaping. Immediately hands went up. “Cancer!" one student called out. "Nicotine,” said another. “Potential,” one student said carefully before elaborating, “I read about a study that found people who use e-cigarettes are three times more likely to smoke.” Heads nodded. "Vanilla," one student said. "Half of my swim team vapes, and they smell like vanilla."
This was my first clue that this wasn't a typical lecture on tobacco. Instead of telling the students what they thought of e-cigarettes and the reasons why, Prochaska and Jackler provided a crash course in critical thinking, arming the teens with a variety of findings and letting them decide what information about e-cigarettes, vaping and hookah was valid, bogus, or in need of further research.
Prochaska showed the class a chart with three columns of data side-by-side. When displayed on a chart that extended between zero and 100 percent on the (vertical) y-axis, the students agreed that three columns appeared to be roughly the same height. Then she asked the students to zoom in on the chart by making the y-axis extend from 0 to about 20 percent. Now differences between the columns of data suddenly looked significant.
Prochaska explained that this trick was applied to data from a New Zealand-led study originally published in the Lancet in 2013 to create the illusion that e-cigarettes helped people quit smoking.
"Statistics can be really useful in science, but they can also be used to, excuse me, 'blow smoke,'" Jackler said.
As the class progressed, Prochaska and Jackler explained what e-cigarettes, vape pens and hookahs are and how they work, and listed some of the studies that have (and have yet) to be done on their safety. “If you spread out the tissue in your lungs it would be about the size of a tennis court - that’s why this is such an efficient way to take in nicotine,” Prochaska said.
“Is a gram of pure nicotine enough to kill someone?” a student asked. “A few grams are enough to kill a kindergarten class," Jackler replied. This prompted a discussion of nicotine poisoning, the additives used in e-cigarettes, and nicotine flavorings with lighthearted names like "Katy Perry Cherry" and "Unicorn Vomit."
Jackler said, “Many companies make flavorings for food. The e-cigarette companies buy and use these flavorings, but they are designed to be ingested, not inhaled. They’ve been tested [for safety] for ingestion but they haven't been tested for use in the lungs."
The class then explored the claim that flavorings don't make e-cigarettes more appealing to kids. Prochaska said, “If kids didn’t like flavors, how could flavors like 'Sweet Tart,' 'Oreo,' 'Fruit Loops' and 'Skittles' still be on the market [in foods]? These are all flavors that are added to nicotine.”
As the class came to a close, Prochaska asked the students to pair off into groups to use their critical thinking skills to examine a variety of tobacco ads from the turn of the century to the present day. The students were asked to identify the ad's mood, design plot, theme, aesthetics and audience/culture. The goal of the exercise was to discern how and when their opinions were being manipulated by a cleverly crafted ad.
“You should be critics," Jackler said. "You should not accept at face value statistics that are presented to you. Be skeptical when you see data you aren’t certain about. If you aren’t sure what they mean, ask an expert. That’s what we do.”
Previously: On yoga, virtual reality and healthy eating: A peek inside Med School 101 and With e-cigarettes, tobacco isn’t the only danger
Photos by Holly Alyssa MacCormick