Vaping bans: How one health crisis prompted a crackdown on another

Why We Wrote This

Some promising trends fall short of real progress. Vaping – once considered safer than cigarettes – has emerged as a public health harm for teens and adults. Has the dearth of research sent solutions up in smoke?

Mike Cardew/Akron Beacon Journal/AP
Caily Stoyanov talks about her life-threatening vaping experience at Revere High School on Oct. 22, 2019, in Richfield, Ohio. Some schools, colleges, and cities have banned the flavored nicotine cartridges believed to be most alluring to teens.

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Once considered a way to wean adults off smoking, vaping is increasingly viewed as a menace. The substantial rise in teen nicotine vaping threatens to undo decades of progress in reducing teen smoking. But the epidemic that has caused the most alarming health effects may well stem from adults using vaping devices to inhale marijuana. These twin crises test researchers and policymakers alike as they search for solutions.

The main culprit appears to be THC vaping by adults. Of the 48 fatalities and nearly 2,300 cases requiring hospitalization, the large majority involve THC – the mind-altering compound linked to the marijuana “high” –  and those over 18. Teenage use of legal nicotine vaping devices has drawn far more attention from policymakers. Schools and cities have banned the flavored nicotine cartridges believed to be most alluring to teens, and Massachusetts’ governor has signed the first statewide ban on all flavored nicotine vaping products. 

Advocates argue vaping legal nicotine saves lives because it doesn’t involve toxic ingredients found in combustible tobacco. But there are as yet no long-term scientific studies on those claims. 

As Dan Romer of Annenberg Public Policy Center at the University of Pennsylvania says, “We’re in a regulatory no-man’s land.”

The online vape store looks legitimate: It warns away those under 21; a customer chat box pops up when you open the home page; there are online coupons, even a Black Friday sale, for the cartridges filled with marijuana ingredients.

But you can’t pay with credit cards, only cash transfers (Western Union or Zelle), gift cards (Amazon or iTunes), or bitcoin. And the brand the store specializes in – Dank Vapes – is probably counterfeit, says the U.S. government.

This unregulated, gray-market corner of the vaping industry plays a large but underrecognized role in a pair of public health crises that are rapidly tarnishing the image of vaping. Once thought of as helping to wean adults off of smoking, vaping is increasingly viewed as a menace, enticing teens to try smoking with cool-looking e-cigarettes and fruity and other alluring flavorings.

The substantial rise in teen nicotine vaping threatens to undo decades of progress in reducing teen smoking. But the epidemic that has caused the most alarming health effects may well stem from adults using vaping devices to inhale marijuana rather than teens finding new ways to get nicotine.

These twin crises, overlapping and intersecting at vulnerable places, such as schools, are testing researchers and policymakers alike as they search for solutions.

“It’s a mess,” says Dan Romer, research director at the Annenberg Public Policy Center at the University of Pennsylvania. “The whole thing is wrapped into a whole lot of uncertainties, because we don’t know if vaping or other liquid nicotine is safe. ... We’re in a regulatory no-man’s land.”

Until recently, vaping was considered safer than smoking. Instead of burning tobacco or marijuana plants, creating tar and potentially other toxins, e-cigarettes or vaping devices warm up liquids containing nicotine or tetrahydrocannabinol (THC), the mind-altering compound linked to the marijuana “high.” But since the spring, public health officials have contended with a fast-moving epidemic of vaping-related lung injuries and fatalities.

This epidemic has led to a backlash against teenage nicotine vaping, even though the main culprit appears to be THC vaping by adults. Of the 48 fatalities and nearly 2,300 cases requiring hospitalization, the large majority involve THC and those over 18, according to the U.S. Centers for Disease Control and Prevention. More than half the cases specifically involved Dank Vapes marijuana cartridges, which the CDC says “appears to be the most prominent in a class of largely counterfeit brands … that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution.”  

The other crisis, involving teenage use of legal nicotine vaping devices, has drawn far more attention from policymakers. Schools, colleges, and cities have banned the flavored nicotine cartridges believed to be most alluring to teens. On Nov. 27, Massachusetts GOP Gov. Charlie Baker signed into law the first permanent statewide ban on all flavored nicotine vaping products as well as flavored tobacco products, including menthol cigarettes.

“I’m so, so proud of Massachusetts,” says Gwendolyn Stewart, director of Tobacco Free Mass, a statewide advocacy coalition for tobacco issues. “It was an incredible step forward for preventing young people from becoming addicted to nicotine.”

Surveys of teens suggest that their nicotine use is on the rise again after decades of declines in teenage smoking. More than half of high school students and a quarter of middle school students have tried a tobacco product, the CDC reported last week, and a third of high-schoolers have used one within the past 30 days. That’s up from 20% in 2017. The teens most commonly use e-cigarettes although often in combination with cigars, chewing tobacco, and other products.

The Vapor Technology Association, representing the legal nicotine part of the industry, is suing Massachusetts, arguing its ban on flavored tobacco products will be detrimental to its members and that a better solution would be to raise the legal age for smoking from 18 to 21.

The industry has had some success with its lobbying efforts. In September, White House officials publicly said they were moving to ban most flavored e-cigarettes nationwide. But in November, after a pushback from vape-shop owners and vaping enthusiasts in person and on social media (#WeVapeWeVote), President Donald Trump backed away from the plan.

The uproar caused by the THC devices, made by unknown people containing unknown substances, has hurt sales of nicotine-vaping companies. “There has never been a stronger argument in favor of legalization and regulation,” says Troy Dayton, CEO of The Arcview Group, an investment and market research firm for the cannabis industry. “This is the equivalent of people dying and going blind from bathtub gin during alcohol Prohibition.”  

The outbreak of lung injuries spread so quickly that researchers are still unsure what has caused it. The CDC has pointed to Vitamin E, which is used to thicken the THC-containing liquid before it is heated, as a potential problem. But as quickly as it spread, the crisis may have already peaked as new reported cases decline.

Law enforcement is also struggling to catch up. Illegal THC liquids are often seized while agents are looking for other drugs. “It’s just too new,” says Katherine Pfaff, a spokeswoman for the Drug Enforcement Administration. “This is absolutely something that we are diligently looking into.”

Advocates argue that vaping legal nicotine saves lives because it doesn’t involve the tar and other toxic ingredients that combustible tobacco does. There are as yet no long-term scientific studies on those claims. And the lines of separation between nicotine and THC and the legal and illegal portions of the industry are not quite as solid as the industry suggests.

In Massachusetts, for example, at least 28 of the 90 people with confirmed or probable vaping injuries inhaled nicotine, not THC, according to the state’s public health department. And of the THC-related cases, five probably involved THC from a legal, state-licensed marijuana dispensary.

In the face of the twin crises, the company often credited with sparking the popularity of vaping devices is fighting a rear-guard action. In the past few months, once high-flying Juul has been sued by local school districts, replaced its top executives, slashed jobs, is reportedly under federal criminal investigation, and has seen China and India seal off their huge markets. It has reduced its offerings to tobacco- and menthol-flavored cartridges in an effort to restore its image.

“We must reset the vapor category and reduce underage use,” Joe Murillo, the company’s chief regulatory officer said in a statement last week. “If we don’t, we will lose a historic opportunity to reduce the harm caused by smoking.”

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