Lung injuries associated with e-cigarettes, or vaping, have now surpassed 2200.
By the end of July, fewer than 200 patients had been admitted for e-cigarette, or vaping, product use associated lung injury (EVALI). Although the explosion of cases arises partly from the growing awareness and diagnosis of EVALI, this outbreak indicates that the use of these products has gotten out of control, particularly in children and young adults.
Among patients hospitalized for vaping-related lung injury, more than 300 were under 18 years of age, with the youngest patient being only 13. Forty-eight people have died, including a 17-year-old boy. Traditional cigarette use usually takes several years before inducing lung injury. To have children reported in these cases suggests that this technology is much more dangerous than previously believed.
Now, lawmakers in multiple states have banned the sale of flavored e-cigarettes, including those sold by JUUL, the top-selling e-cigarette brand in the United States. For months, the Trump administration has planned to enforce the ban at a national level. However, the president recently raised concerns that a ban would promote black market sales of more dangerous, lower-grade products, such as those containing vitamin E acetate, which has been found in more than two dozen lung fluid samples from EVALI patients.
It is reasonable to be concerned that this ban would fail given our country’s unsuccessful history of prohibiting alcohol and marijuana. The difference here, however, is that states do not want to totally ban vaping products, just the flavors. Flavors — be it menthol or mango — are the primary reason children report using e-cigarettes. With over a quarter of high schoolers using tobacco products, and cultural norms being a major driver for tobacco use, the best action the country can take is to limit access to their most attractive and addictive forms. Not only would this limit use by children who currently vape, but it would also reduce uptake by new users.
Other countries have successfully banned flavored e-cigarettes, including France. France has struggled for years with a high smoking rate — a whopping 40 percent of French 17-year-olds smoked as of 2016. Yet, the country recognized the attraction of flavored vaping products early on and banned them in 2016 before they could become uncontrollably popular. Subsequently, current e-cigarette use (reported as use in the last 30 days) among French citizens aged 15 to 75 years fell from 6.0 percent in 2014 to 3.8 percent in 2017. Furthermore, “only” 16.8 percent of French 17-year-olds used e-cigarettes in 2017 compared to 27.5 percent of American high schoolers in 2019. Despite the concern that banning flavored e-cigarettes may limit an avenue for smoking cessation, from 2016 to 2017, 1 million people also quit smoking in France.
Some may argue that EVALI is only caused by vaping products containing THC, a derivative of marijuana. While THC use is more common among admitted patients, 13 percent of EVALI patients report exclusive use of nicotine. Regardless, more than half of EVALI cases occur in patients less than 25 years of age and sixteen percent in patients under 18. Nicotine itself damages the adolescent brain, which continues to develop until age 25, including regions which control attention, learning, mood, and impulse control. One e-cigarette pod from companies like JUUL contains as much nicotine as a pack of 20 traditional cigarettes; clearly, teenagers can quickly consume dangerous levels of these products.
In addition to the nicotine, the flavors themselves can be toxic. Cinnamon flavoring, known as cinnamaldehyde, may damage lung tissue and predispose to respiratory infection. Even though JUUL voluntarily suspended sales of flavors other than tobacco, menthol, and mint, these may not be any safer. Recent research shows that many e-cigarettes contain dangerous levels of pulegone, a carcinogen found in mint plants and linked to liver cancer. The risk of this chemical is significant enough that the U.S. Food and Drug Administration already banned synthetic pulegone as a food additive in 2018. Yet, mint is the most popular flavor among high school students who use JUUL. Regulations are thus needed to prevent the medical consequences of these flavorings, beyond combating addiction itself.
If the shortness of breath, fevers, and vomiting are not enough to stop teens from using e-cigarettes, legal or economic tactics may be necessary. Whether those involve multiple state bans or a federal ban against flavorings, a price hike, or even raising the minimum age of sale, lawmakers need to take action to protect any more young adults from getting hurt.
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