The titles of two congressional hearings held yesterday give you a sense of how serious Democratic legislators are about understanding health issues related to vaping. A subcommittee of the House Energy and Commerce Committee considered "Legislation to Reverse the Youth Tobacco Epidemic," while a subcommittee of the House Appropriations Committee heard testimony about "E-Cigarettes: An Emerging Threat to Public Health." The first title assumes a "youth tobacco epidemic" that does not exist, while the second conflates black-market cannabis products, which have been implicated in the vast majority of vaping-related lung injuries reported in recent months, with legal e-cigarettes that offer smokers a much less hazardous source of nicotine.
Since 2011, according to the National Youth Tobacco Survey (NYTS), the share of high school students who say they have smoked cigarettes in the past month has fallen from 15.8 percent to 5.8 percent. In this context, the "youth tobacco epidemic" perceived by members of Congress is nonsensical.
Counterintuitively, the phrase refers not to cigarette smoking but to use of e-cigarettes, which do not contain tobacco and do not burn anything. During the same period when adolescent smoking reached record lows, the share of high school students who reported past-month e-cigarette use in the NYTS rose 18-fold, from 1.5 percent in 2011 to 27.5 percent in 2019.
While there may be legitimate reasons to be concerned about that trend, increased tobacco use is not one of them. In fact, the downward trend in smoking among teenagers and young adults accelerated as e-cigarettes became more popular, which suggests that people who otherwise would be smoking are vaping instead. Given the huge difference between the dangers posed by smoking and the dangers posed by vaping, that shift represents an unambiguous improvement in terms of health risks.
Unsurprisingly, the hearing on the nonexistent "youth tobacco epidemic" was stacked heavily against e-cigarettes. The subcommittee heard from Dorian Fuhrman, co-founder of Parents Against Vaping E-Cigarettes (PAVE); Phillip Gardiner, senior program officer at the University of California's Tobacco Related Disease Research Program; Matthew Myers, president of the Campaign for Tobacco-Free Kids; and Susanne Tanski, a pediatrician representing the American Academy of Pediatrics. All four expressed alarm at the dramatic rise in adolescent vaping and endorsed a federal ban on the flavored e-cigarettes that former smokers overwhelmingly prefer.
At the hearing, Rep. Frank Pallone (D–N.J.), chairman of the House Energy and Commerce Committee, touted his mendaciously named Reversing the Youth Tobacco Epidemic Act, which includes a ban on e-cigarette flavors. "We are facing a serious problem that needs a comprehensive solution," Pallone said in his opening statement. "We simply cannot lose another generation to a lifetime of nicotine addiction." Tanski likewise argued that "adolescents simply do not stand a chance" of avoiding addiction when they try Juul, the dominant e-cigarette brand, because it delivers nicotine in an especially alluring way.
Data from the NYTS, the same survey that has generated the panic about adolescent vaping, contradict such claims. A recent analysis of the 2018 NYTS results found that just 1 percent of high school students who had never used tobacco reported vaping on 20 or more days in the previous month. Among vapers who had never smoked, University College London health psychologist Martin Jarvis and his collaborators found, less than 4 percent reported craving nicotine; just 3 reported wanting to vape within a half-hour of waking up. Meanwhile, 62 percent said they had used e-cigarettes on 10 or fewer days in their lives. These findings are plainly inconsistent with Pallone's fear that e-cigarettes are hooking an entire generation on nicotine and Tanski's assertion that addiction is inevitable once a teenager tries Juul.
"Data from the NYTS do not support claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes, nor concerns that declines in youth tobacco addiction stand to be reversed after years of progress," Jarvis et al. write. "Among current e-cigarette users who had never tried tobacco products, responses consistently pointed to minimal dependence."
Among teenagers who have smoked cigarettes, frequent vaping and signs of addiction are much more common. But as Jarvis et al. note, the evidence indicates that vaping, by and large, is replacing smoking among these e-cigarette users, which by any rational standard should count as a public health victory.
The only witness at the Energy and Commerce subcommittee hearing who highlighted the harm-reducing potential of e-cigarettes was Boston University public health professor Michael Siegel, a physician and longtime anti-smoking activist. Siegel warned that Pallone's proposed ban on flavored e-cigarettes, like a similar ban that the Food and Drug Administration (FDA) plans to impose, would "create a new black market for flavored e-liquids," products of unknown provenance and composition that pose special hazards and may be contributing, along with illegal THC vapes, to the recent outbreak of acute respiratory illnesses, which involved about 1,300 cases and 26 deaths as of October 8.
Siegel also emphasized the impact that Pallone's ban would have on smokers who have switched to vaping. "More than 2.5 million adult smokers in the U.S. have quit smoking completely by switching to electronic cigarettes, and most of these ex-smokers rely on flavored e-liquids to keep them off of real cigarettes," he said. "If flavored e-cigarettes are banned, there is no question in my mind that many of these ex-smokers will return to cigarette smoking. Most of those who don't will turn to a new, potentially dangerous black market that would be created by this legislation."
The House Appropriations subcommittee hearing was similarly slanted against e-cigarettes. Four of the five witnesses emphasized the hazards of vaping without clearly distinguishing between THC and nicotine products or between legal and black-market products. But a careful reading of testimony by one of those witnesses shows why such distinctions are important.
Anne Schuchat, principal deputy director of the U.S. Centers for Disease Control and Prevention (CDC), reported that in cases where the information was available, just 13 percent of patients with respiratory symptoms have said they vaped only nicotine. She also noted that "information about the use of e-cigarettes or other vaping products relies largely on self-report, and interviewees may be hesitant to share information about their use of substances such as marijuana." In other words, the role of black-market cannabis products may be even bigger than the CDC's numbers suggest.
"Based on these findings, we believe THC-containing products may contain chemicals or components that are contributing to this outbreak, and that most of these products appear to be obtained from informal sources like friends and family [or] off the street," Schuchat said. "However, because nicotine-containing products have been reported to be used, either alone or in conjunction with THC-containing products, we cannot exclude the possibility that nicotine-containing products may have a role. No one product, brand, chemical, or additive has been determined to be the cause of these lung injuries."
That muddled message is dangerous for two reasons. First, it does not give cannabis consumers a clear warning about the hazards of black-market THC vapes. Second, it scares current and former smokers away from potentially lifesaving products by implying that legal, nicotine-delivering e-cigarettes might be deadly. The CDC and the FDA both caution that former smokers who have switched to vaping should not return to their old habits, which are indisputably more dangerous. But the CDC's evidence-free suggestion that products like Juul might play a role in these lung diseases undermines that crucial point.
Meanwhile, Meredith Berkman, another co-founder of the anti-vaping group PAVE, explicitly linked the "terrifying" outbreak of lung disease to "the vaping epidemic" among teenagers who use e-cigarettes like Juul, even though such products have been used by millions of Americans for years without reports of life-threatening respiratory symptoms. Renée D. Coleman-Mitchell, commissioner of the Connecticut Department of Public Health, drew the same connection, again without any evidence that legal e-cigarettes are responsible for these illnesses. Stanford University pediatrician Bonnie Halpern-Felsher likewise cited "the current concern over the vaping-related lung illnesses and deaths that may or may not be caused by nicotine e-cigarettes."
Washington, D.C., psychiatrist Sally Satel, a resident scholar at the American Enterprise Institute, was the only witness who avoided conflating the hazards of black-market products with the hazards of legal e-cigarettes. "The lung injury problem is a story of the dangers of the black market, not of vaping," she noted. "Consumers have been using commercially available vaping devices and nicotine products for 10 years without a single recorded death or any surge of illnesses…until this summer. What we are observing today is consistent with a relatively acute contamination."
Implying that all vaping products are equally dangerous, Satel warned, "is a hazard to smokers who have already switched to e-cigarettes and now risk return to smoking combustible cigarettes." She also noted the problems with banning flavored e-cigarettes. "A ban on flavors is completely irrelevant to the outbreak of lung disease," she said. "Eliminating flavored nicotine e-liquids will not prevent further cases of lung disease because those products had nothing to do with the outbreak." Worse, Satel added, "a sizeable number of vapers will resume smoking" once the products they prefer are no longer legally available, while "others will seek out counterfeit enterprises" offering mystery e-liquids that may contain dangerous additives or contaminants.
"Vaping products are intended to help smokers relinquish cigarettes," Satel said. "They help adult smokers to quit smoking and are substantially less dangerous than smoking. As with any public health intervention, the unintended consequences of regulatory policies aimed at teen vaping must be kept in the forefront of our thinking. To appreciate why curbing adult access has such significant public health implications, we need to acknowledge the vast health benefits of vaping for smokers….We can protect teens through more aggressive barriers to access. At the same time, we can save smokers' lives and combat the leading cause of preventable death in the world by preserving adult smokers' access to a valuable smoking-cessation method."
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