Cigarettes kill more people each year than our enemies did in the nation’s wars over the last seven decades. For that to change, existing cigarette smokers would need to quit or obtain nicotine through something less dangerous. Enter electronic cigarettes, also known as “e-cigarettes,” “vapes,” or Electronic Nicotine Delivery Systems (ENDS).
E-cigarettes are electronic devices that deliver nicotine to smokers through inhalation. By so doing, they satisfy a smoker’s craving for its addictive properties, while mimicking the use of traditional cigarettes, which enables users to feel as if nothing has changed. Some vapes resemble ordinary cigarettes, while others could be confused with pens, flash drives, or cell phone power banks. Irrespective of their appearance, the majority of e-cigarettes include a power source such as a battery, a liquid storage compartment, a heating element to “vaporize” the liquid, and a mouth-piece to inhale the aerosol. The typical liquid, sometimes referred to as “e-liquid,” varies in ingredients, but ordinarily includes colorless, odorless, sweet-tasting, viscous liquids in various flavors. In addition to standard nicotine-infused liquids, e-liquids can contain “street” drugs or their derivatives, especially delta-9-tetrahydrocannabinol (THC), the psychoactive ingredient in cannabis.
The addictive chemical found in traditional cigarettes is nicotine. While dangerous, nicotine is not a carcinogen; tar and other chemicals released from burnt tobacco play that role. To help smokers quit, the Food and Drug Administration has approved a variety of what are known as “nicotine replacement therapies” (also known as NRTs), such as patches, gum, lozenges, inhalers, and nasal sprays. In 2007, vaping emerged as an additional option. Unfortunately, there are two major concerns with vaping.
Vaping and Minors
One is that an increasing number of juveniles use e-cigarettes. The danger of e-cigarette use for teens and young adults is perhaps the most recognized issue with vaping. According to the US Surgeon General, despite the prohibition of e-cigarette sales to children under the age of 18 (or 21 in some states), vaping among youth is increasing. Between 2011 and 2015, the total per-centage nationwide of high school students who had vaped in the previous 30 days increased from 1.5 percent to 16 percent. From 2017 to 2018, youth vaping increased by 78 percent after declining in the preceding two years. In 2018, 20 percent of high school students vaped at least once in the previous 30 days. The result is an intergenerational problem. Adults might benefit from e-cigarettes if they enable adults to quit smoking, which would be a major health benefit. On the other hand, if e-cigarettes addict minors to nicotine that would be a major health detriment, because nicotine could adversely affect the labile juvenile brain.
The other concern, which emerged only in 2019, is far more serious.
The EVALI Epidemic
In 2019, e-cigarettes captured national headlines due to a sudden outbreak of what the Centers for Disease Control (CDC) is calling “e-cigarette or vaping associated lung injury” or EVALI. As of November 20, 2019, the CDC has documented 2,290 cases of EVALI from 49 states (Alaska being the only exception), the District of Columbia, Puerto Rico, and the US Virgin Islands. The facts of those cases are scary. Forty-seven patients have died; physicians placed others on life-support or in medically induced comas. Surgeons also performed the first double lung transplant due to vaping (on a 17-year-old student athlete).
Two factors highlight the EVALI concerns. One is that, in line with available data for e-cigarette use, the median age of EVALI patients for whom age data is available is 24, with 77 percent of patients under 35. The other factor is that only 13 percent of the reported EVALI patients claimed to use nicotine-containing e-cigarette liquids exclusively. By contrast, 35 percent of the sample reported exclusive use of THC-containing vaping liquids, and 83 percent reported using THC-containing liquids in conjunction with other products. After conducting laboratory analyses of fluid samples collected from some patients’ lungs, the CDC identified THC in 82 percent of the samples, and vitamin E acetate, a colorless and odorless substance used especially in THC-containing e-cigarette liquids as an additive, in all of the samples. It seems that minors are using e-cigarettes to smoke marijuana without giving away what they are doing.
The combination of THC and vitamin E acetate is particularly troublesome. The latter is an ingredient in nutritional supplements and cosmetic products, and it is harmless when ingested or applied to the skin. Inhaling the vaporized form of vitamin E acetate, however, is potentially deadly. Vitamin E acetate is viscous and returns to that state after being vaporized and inhaled, coating a vaper’s lungs and hindering his or her ability to inhale air and process oxygen from it. The identification of vitamin E acetate as potentially the main culprit for EVALI by the CDC points the finger at marijuana vapes and THC-laden e-cigarette liquid. As a result, CDC officials have explicitly warned users of THC-infused vaping products immediately to discontinue that practice.
Vaping and Marijuana
The vaping of THC by minors aggravates their already problematic use of marijuana. The regular or heavy use of marijuana beginning in one’s minority can pose a serious risk of problems, given the labile state of the juvenile brain, particularly if someone succumbs to long-term use. The US Surgeon General recently issued a statement stating that science does not yet know the long-term effects of marijuana use, and advising pregnant mothers and youths not to assume those immense risks.
One reason for concern is that today’s marijuana is far more potent than the drug used by previous generations. Years of careful selective breeding has increased the THC content of commonly cultivated plants from 4 percent in 1995 to 12 percent in 2014. Now, just five years later, some marijuana plants available in dispensaries have an average THC concentration as high as 23.2 percent. Marijuana concentrates can contain THC levels as high as 75.9 percent. We do not yet know what will be the long-term effects of heavy marijuana consumption beginning in youth of such high potency marijuana. As The New York Times reported, a professor of medicine at the University of California, San Francisco, recently sent a letter to Congress stating that “very little is known about the safety or effects of vaped cannabis oil,” and that marijuana-containing e-liquids may a “have harmful, toxic effect on users, including the potential for causing and/or promoting cancer and lung disease.” Proponents of marijuana legalization have acknowledged the uncertainty surrounding vaping cannabis, with the president of the board of the United Cannabis Business Association in California stating that, regarding marijuana e-liquid, “we don’t know what the chemical composition is… and we especially don’t know what the chemical composition is once it’s been combined, heated and inhaled.”
This lack of knowledge of both marijuana use generally and mari-juana use in e-cigarettes has directly contributed to the thousands of individuals suffering from serious lung illness in the last six months.
What we do know now, however, is that vaping THC-infused liquids with vitamin E acetate can lead to death in the short term by coating the lungs with a viscous substance that prevents them from transferring oxygen out of inhaled air into the blood. Unfortunately, the FDA has so far declined to take aggressive action against businesses that sell marijuana, either in a smokable or edible form, for medical or recreational use in states that have legalized those practices. Perhaps the FDA has decided to husband its resources and credibility by remaining on the sidelines during the recent controversy over the enforcement of the federal laws prohibiting the very conduct that many states now permit under their own laws. But the number of deaths and serious injuries from vaping demands action.
The Future of Vaping
E-cigarettes have the potential to assist in reducing or eliminating use of traditional tobacco cigarettes. It is important, however, that America’s youth not gain access to these products. Fur-thermore, legislators and public health officials must be serious about the potential risks of vaping marijuana.
So far, there is no reason to believe that Congress is willing to do so. The House Judiciary committee recently approved a bill that would legalize marijuana nationwide without addressing the problem discussed above. As the death and hospitalization toll increases on a weekly basis from EVALI, the CDC and the FDA are on the right track by identifying harmful chemicals. By doing so, public health officials will be able to craft effective regulatory proposals in order to address the most dangerous aspects of e-cigarettes without banning them altogether.
E-cigarettes have the potential to move generations of smokers towards less harmful alternatives. Yet, the widespread use of vapes to consume marijuana calls for immediate action by the federal government. The issues posed by the vaping of marijuana must be studied and addressed.
Lucas Drill is a Visiting Fellow at The Heritage Foundation. Paul J. Larkin, Jr., is the John, Barbara & Victoria Rumpel Senior Legal Research Fellow at The Heritage Foundation.