Clearing the Air on Vaping

vaping illness

For those of you who are foreigners to the world of smoking, when you first heard the word “vape” you may have thought it was a new-fangled way of talking about the weather.

At least I did. (Vape would be a pretty edgy way to discuss atmospheric water vapor and vapor pressure calculators.)But it’s not. This kind of vapor is not of the naturally occurring variety — it’s the kind that’s emitted from e-cigarettes, and it’s been on people’s tongues — and lungs — lately, because there have been a number of sudden onsets of illness, and even deaths, linked to the practice.

After months of investigating, the CDC announced on November 8 that it has finally made some headway in identifying the rogue agent in vaping products.

So what’s been going on — or really, what’s been going wrong — with e-cigarettes and vaping? How dangerous is it? Is it safer than ordinary cigarettes?

A Beginner’s Guide to Vaping

First, what exactly is vaping?

Think e-hookahs, vape pens, tank systems, mods and electronic nicotine delivery systems (ENDS), all variations on the same concept.

It’s most commonly done via electronic e-cigarette, which uses a liquid mixture of nicotine, flavors, and chemicals, which are then vaporized and inhaled.

You may also have been wondering why there are actual vape shops devoted solely to the sale of vaping products. But once you come to realize that there are more than 15,000 e-juices out there (traditional ones like vanilla, cinnamon and buttery popcorn, as well as colorful ones like Blue Voodoo, Surf Cake and Shurb), it’s more of a mystery how one shop alone can handle all that product.

vaping illness
Juul mint flavored e-cigarettes at a shop in San Rafael, California. (Justin Sullivan/Getty Images)

Because vaping simulates the activity of smoking, but without actually burning tobacco, it has been promoted as a safer alternative to traditional cigarettes. And, the FDA only gained regulatory power over vaping in 2016, so companies that have been on the market since earlier than that date (such as the market leader Juul) are accessible without having FDA authorization.

In other words, this is a pretty unregulated market. Now that the FDA has jurisdiction over e-cigarettes, manufacturers have until May 2020 to retroactively apply for authorization. They need to demonstrate that their products are “appropriate for the protection of public health”; otherwise, they may be taken off the shelves.

Something to bear in mind while considering this topic is that there is significant financial incentive to manufacture and sell vapes/e-juices. This means efforts to restrict them are likely to be protracted and combative.

Mysterious Illnesses

Sounds like a fiction thriller, but it’s very real, and it has presented a serious conundrum for federal and state public officials, as well as for vaping manufacturers, who fear a blanket ban on their products.

The CDC has, up to the point of this article’s writing, confirmed 2,051 cases of vaping-related illnesses across 49 states (there have been none in Alaska), as well as a few dozen deaths.

 

The outbreak seems to have begun in March, with no single ingredient being identified as the culprit. However, most of the patients stricken with this mystery illness, which the CDC is now calling EVALI — e-cigarette, or vaping, product-use-associated lung injury — were using vaping products that contained THC, a psychoactive ingredient in marijuana.

That, at least, is the theory.

As of now, the CDC acknowledges that “no one compound or ingredient has emerged as the cause of these illnesses to date; and it may be that there is more than one cause of this outbreak.” Its investigation is ongoing.

However, a breakthrough was reported on November 8 from the deputy director of the CDC, identifying vitamin E acetate, an additive used in the production of vaping products, as the possible culprit. The new findings are significant, she said in a press briefing, but not conclusive. There may be other ingredients behind the outbreak. A sample of lung fluid from 29 EVALI patients across 10 states all revealed traces of vitamin E acetate, hence the new conclusion.

Despite the narrowing of the investigation, the agency is still recommending all users stay away from vaping products containing THC, “particularly those obtained off the street or from other informal sources, e.g. friends, family members, illicit dealers,” since, as of now, products containing THC are “linked to most of the cases and play a major role in the outbreak.”

The CDC goes further, and recommends avoiding vaping products until the investigation has reached a certain conclusion.

Safer Than Smoke?

Barring the recent emergence of vaping-related illnesses, is vaping actually safer than smoking in the long term?

“Probably yes,” says Dr. Steven Bernstein, professor of emergency medicine and public health at Yale school of Medicine, in an interview with Hamodia. (Dr. Bernstein develops screening and treatment interventions for tobacco users in hospital settings, and programs to train providers in tobacco control.)

For Dr. Michael Seigel, of the Department of Community Health Sciences at the Boston University School of Public Health, the answer is more definite: “Absolutely,” he says.

Dr. Bernstein says, “E-cigarettes haven’t been around long enough to know for sure, but because e-cigarettes contain few to none of the carcinogens found in cigarettes, and very few of the other harmful compounds found in cigarettes, they are probably safer.

vaping illness
A sign about vaping in front of Gone With the Smoke Vapor Lounge in San Francisco in 2016. (Justin Sullivan/Getty Images)

“It is also important to remember,” Dr. Bernstein points out, “that most of these vaping-related lung injuries are due to the vaping of cannabinoid oils, i.e., products derived from marijuana. There is no convincing evidence that using e-cigarettes without marijuana-derived compounds causes lung injury”

He then adds that smoking kills 480,000 Americans every year, while vaping lung injuries have killed around 40.

“There is no question that vaping e-cigarettes is much safer than smoking,” agrees Dr. Seigel. “While tobacco smoke contains more than 10,000 chemicals, including more than 60 known human carcinogens, e-cigarette aerosol contains only a small number of chemicals and only a couple of carcinogens, but only when the e-liquid is overheated. With proper regulation, e-cigarettes can be manufactured in a way that minimizes exposure to unwanted chemicals. The key is careful temperature control.”

For Ned Sharpless, FDA acting commissioner from April to November 2019, however, e-cigarettes and vaping are anything but safe.

He writes on the FDA’s website: “When I was Director of the National Cancer Institute (NCI), I would be frequently asked ‘What topic in cancer research and cancer care keeps you up at night?’ I always answered this question the same way: ‘Tobacco control in the era of e-cigarettes.’”

He goes on to describe what that means. Although he acknowledges that vaping is theoretically a windfall for society because it acts as an alternative to smoking, it has created a new social consequence: “The explosion of use and nicotine addiction in children. … After years of witnessing a steady decline in the use of tobacco products by children and young adults, we are now seeing a rapid resurgence of the use of tobacco products in these populations.”

This claim bears out just by looking at the data of the current EVALI patients, 79% of whom are under age 35 and 54% of whom are under the age of 24.

With a number of unknowns surrounding e-cigarette use, this upward trend of young people vaping is concerning. He delineates what those unknowns are:

It is unknown whether these products are harmful over the long term. It is unknown whether they are actually effective in guiding smokers away from combustible cigarettes, and it is unknown whether vaping can actually act as a gateway activity to traditional smoking.

With all those unknowns, Dr. Sharpless is intent on warning society off of vaping, while still recognizing its ability to help traditional smokers.

“There is great potential to significantly reduce the national burden of cancer and other diseases if we can help addicted smokers quit what is perhaps the most dangerous product that is mass-marketed in America today,” he writes. “But there is also the terrible risk of having millions of … Americans become lifelong addicts to a new class of products that are not safe and possibly transitioning to other tobacco products that are known to be deadly. I considered this topic as one of the leading issues facing American public health when I was leading the NCI, and that view has not changed.”

States React

While the FDA collects data and determines its course of action, antsy states have been taking measures of their own.

Michigan, under Governor Gretchen Whitmer’s leadership, is the first state to announce its intent to take action, instituting an emergency ban on many of those 15,000 vaping flavors except tobacco. She went further, saying that retailers would be forbidden to use words like “clean,” “safe” and “healthy” to advertise their merchandise. The ban was enacted on September 18; however, a month later, a Michigan Court of Claims ruled against the ban, arguing that it was an overstep. Flavored vaping products are now available once again.

While Michigan was the first state to take action, New York was the first state to succeed with that action. Under Governor Cuomo’s leadership, the state has banned the sale of fruity-flavored e-juices; violations would be punishable with a $2,000 fine. Critics of the governor say the ban does not go far enough, because it still allows mint and menthol flavored products, which are nearly as popular among teens as fruity ones.

vaping illness
Members of the Los Angeles County Department of Public Health at a press conference in September, announcing an investigation into deaths associated with vaping. (Mark Ralston/AFP via Getty Images)

Massachusetts went even further, banning the sale of all vaping flavors, including tobacco, online and retail.

A number of other states have taken similar steps to limit or completely restrict these products.

Many officials are calling this a “public health crisis for children” and a “national emergency” (barring Alaska, that is), lending urgency to their calls for vaping bans.

Critics of these executive actions, ranging from vaping users to vaping retailers to vaping manufacturers, have been pushing back against state decisions, either in the form of lawsuits or protests, some even appearing at President Trump rallies with signs boasting: “We vape, we vote!” One of the dominant arguments has been that bans will push consumers toward cigarette smoking to fill the gap.

So, are state governments that ban vaping products making the right decision?

For Dr. Seigel, the answer is a blunt “No.”

“These policies are going to push ex-smokers back to smoking. They are also going to create new black markets for e-liquids, which create dangers of their own. If the recent outbreak teaches us anything, it is the dangers of having an unregulated black market.”

Dr. Bernstein has a different take on this.

“From a public health perspective, it is reasonable to restrict the sale of vaping products; only individuals age 21 and older should be permitted to buy e-cig/vaping products. It is also reasonable for the FDA to impose restrictions on flavorings, packaging, marketing,” he says.

“It is unclear whether this will push consumers back towards smoking. That may happen sporadically, but it remains more likely that e-cigarettes may help some confirmed smokers reduce/eliminate their use of combustible tobacco, e.g. cigarettes/cigars/pipes.”

FDA Proposal

There are two basic concerns here that are being somewhat conflated — fears about the THC vaping-related illnesses and deaths, and fears about the rising numbers of vaping use among children.

The FDA hopes to deal both of those concerns one, swift blow.

Announcing in September its intention to ban most vaping flavors except for tobacco, the agency hopes to curtail child-vaping as well as the EVALI outbreak.

The FDA intends to ban popular fruity flavors, as well as menthol and mint e-cigarettes, from stores and online sellers, leaving just tobacco-flavored products.

Health and Human Services Secretary Alex Azar explained the rationale for this decision in an interview with The Wall Street Journal.

“It is always better to use e-cigarettes or nicotine-replacement therapy instead of combustible tobacco,” he said. “We are striking this balance between an off-ramp for adults but preventing the on-ramp for kids.”

vaping illness
House Economic and Consumer Policy Subcommittee Chairman Rep. Raja Krishnamoorthi (D-Ill.) points to a poster showing similarities between Marlboro cigarette ads and JUUL Vaping paraphernalia, during a House Economic and Consumer Policy Subcommittee hearing that heard testimony on JUUL’s role in the youth nicotine epidemic, last July. (Mark Wilson/Getty Images)

Being that kids are attracted to many of the fruity flavors, regulation like this could help deter vaping.

Is this course of action wise? Will taking fruity vapor flavors off the market close the “on-ramp” for teens, but leave an “off-ramp” for adults?

Dr. Bernstein believes that’s a reasonable possibility.

Dr. Seigel believes it isn’t.

“The tobacco e-cigarettes are not much of an off-ramp,” he says. “Very few smokers use them. More than 2 million ex-smokers in the U.S. rely upon flavored e-cigarettes to stay off of real cigarettes. If these products are taken off the market, large numbers of ex-smokers are going to return to smoking.”

And there’s even a great bit of market evidence to back that up. “Stock analysts are predicting that a flavored e-cigarette ban would lead to a substantial increase in cigarette consumption, and they are recommending that investors purchase tobacco stocks now because of that,” he adds.

Just like the ongoing smoking melee, vaping seems poised to become the new public health enemy number one. Although it poses nowhere near the hazards of traditional smoking, rising concerns about lung illness and childhood addiction mean that governing bodies will throw all their weight against this one. It only bears waiting to see whether manufacturers’ objections and public demand will win out.

Get ready for a long, drawn-out battle.

What’s your experience with vaping? Please send your stories to prime@hamodia.com

***

A conversation with Aryeh, a 41-year-old vaper

 

When did you start vaping?

Seven years ago.

Were you first a smoker?

Yes.

Did it help you get off of smoking?

Yes.

Were you deliberately trying to stop smoking?

Yes.

Are you at all concerned about the recent lung illnesses being reported, that are linked to vaping?

No.

Why?

The main reason is because I have negioyos, but also because most of them are marijuana-based flavors. There’s also a Jewish company that doesn’t put in dangerous ingredients.

What is that company?

It’s called Drop Smoke. It even has a hechsher.

Do you know any other vapers?

Yes, I have a lot of friends, unfortunately, who vape.

You say “unfortunately.” Is that because you recognize it’s unhealthy?

Of course it is. But vaping is for sure better than smoking. And it’s easier. Smoking is very limited; you need to go outside; you don’t want people to smell you. I had to think about it before I would smoke. You don’t want your kids to know; you’re much more locked up. Vaping is easier, more accessible, more opportunity.

Are you concerned about the rise in vaping among children?

One hundred percent. I’ve even heard of eighth-grade boys getting caught with it.

Do you think yeshivos should make rules about it, the same way they mostly do about smoking?

Yes. But it’s extremely hard to stop it, because it’s easier to hide.

Any other points you would raise regarding this topic?

Some of my friends use vapes, but it did not help them stop; it just made them want the nicotine more.

Why would that be?

Nicotine is addictive; the more you have, the more you want.

[Vaping] is also very addictive, because it’s a good flavor. Smoking leaves your mouth dry. You have to get used to it. Vaping is geshmak, very soothing and enjoyable, so it’s easier to get addicted.

***

A Conversation with Joe Cweiber, President of Drop Smoke, a company that manufactures and sells vaping products.

I’m calling from Hamodia; we’re doing a story on the recent vaping illnesses and the FDA proposal. Would you be available to speak with me?

Well, that depends. Are you doing a story on “vaping illness” or the black-market THC cartridge illnesses?

It’s really a general story, exploring what vaping is, how it compares to smoking, the recent illnesses, etc.

Listen, I’m not excited about giving an interview, because I’ve seen some publications cast vaping in a terrible light, and it’s really not the case. And it’s really important not to give people false information.

I will send you a copy for review; I understand your concern. Can you tell me a little about your company first?

We’ve been around since 2011; we manufacture e-liquids for electronic cigarettes.

What kinds of flavors do you sell?

We have over 100 flavors.

All kosher?

Yes, certified by Hisadchus CRC.

So why do you believe these recent vaping illnesses aren’t of concern?

We knew from the beginning that this wasn’t an issue with e-juices. If you read the CDC update, then you know it’s linked to vitamin E acetate, which is used in THC.

THC itself needs a carrier, and vitamin E acetate is the carrier. There are some legal THC products, but they don’t use vitamin E acetate. That’s a cheap ingredient that helps break down the THC so it can be vaped. That’s why I said earlier, this story is about the black-market THC products which use vitamin E acetate, not about regular vaping.

OK, that sounds likely, but the CDC hasn’t ruled out that there can be other ingredients that are causing the illnesses. They’re still saying: “Since the specific compound or ingredient causing lung injury [is] not yet known, the only way to assure that you are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products.”

Yes, that’s because a number of the kids with this lung illness don’t want to admit that they used THC.

And also, the FDA wants to be able to put in place
a ban.

Ask yourself this question. If they don’t know exactly what is causing the illness, then why does the FDA proposal only recommend banning flavored juices, but keeping tobacco flavors on the market? If they were that concerned, it would be a blanket ban on all products.

I hear what you’re saying. It’s probable that there are two issues being conflated here — the concern over the lung illnesses, and concern over childhood vaping (children prefer flavored vapors, hence the urgency to ban flavors rather than traditional tobacco flavor).

What is your opinion on childhood vaping though?
Do you see it as a concern?

I’ve pushed for a higher age limit on vaping even before there was an age restriction.

We had our own age restrictions at our company. I’ve had fathers crying to me about their children vaping.

A store that sells Dipsy Doodles and Mountain Dew should not be selling electronic cigarettes. You should only be able to buy those products in a licensed vape shop.

Listen, countless people have stopped smoking because of vaping.

In the United Kingdom, there are vape shops in hospitals; that should tell you something about how vaping is viewed in other countries.

In the U.S., big tobacco has had … a big effect on the way people view electronic cigarettes. The Royal College of Physicians in the U.K. came out with a report that electronic cigarettes are 95% better than smoking. [If] you want 100%, then you need to stop completely.

We are dealing with companies that are reliable, with clean rooms, and no dangerous ingredients. If you have a clean liquid you’re putting into your device, it is 95% better than smoking a cigarette.

We’ve also created 13 levels of nicotine, so you can downgrade slowly.

We also sell non-nicotine flavors.

Listen, I started smoking at 13. It’s terrible, it’s so dangerous. My background is in finance, but I got into this because I want to help people. It helped me. I haven’t smoked in years because of it.