The Truth About the Vaping Crisis (Ep. 398)
After more than 40 deaths, some states and cities have banned vaping products, many of which are used as smoking-cessation devices. Meanwhile, nearly 500,000 people die each year from smoking, and cigarettes are still widely available. (Photo: Burton/Getty) A recent outbreak of illness and death has gotten everyone’s attention — including late-to-the-game regulators. But would a ban on e-cigarettes do more harm than good? We smoke out the facts. Listen and subscribe to our podcast at Apple Podcasts, Stitcher, or elsewhere. Below is a transcript of the episode, edited for readability. For more information on the people and ideas in the episode, see the links at the bottom of this post. * * * Unless you’ve been hibernating, you’ve probably been hearing about the dangers posed by e-cigarettes and vaping. CBS News: Two more people have died from vaping-related illnesses, this time in Minnesota. This brings the nationwide toll to 31 deaths across 22 states. Good Morning America: Public health officials report there are nearly 1,300 probable or confirmed injuries related to vaping in 49 states. These cases involve a severe respiratory ailment that’s been labeled EVALI, or “e-cigarette, or vaping, product-use-associated lung injury.” Doctors in Detroit recently performed double lung-transplant surgery on one EVALI victim. Even though people have been vaping for years, the deaths are new, and the news has been met with something between alarm and panic. PBS NewsHour: The Federal Government today warned Americans not to use e-cigarettes following several mysterious deaths linked to vaping. The caution is understandable. More than 40 million people around the world now vape, up from just 7 million less than a decade ago. In the U.S., roughly 1 in 5 high-school kids vape. Vivek MURTHY: I think that when it comes to especially the health of our children, we cannot afford to take risks. That is former U.S. Surgeon General Vivek Murthy. MURTHY: And already millions of children are using e-cigarettes who should have never been exposed to these devices. But while the U.S. is trying to beat back the tide of vaping, there’s another country that’s been encouraging it. Michael SIEGEL: In the U.K., they’ve actually embraced electronic cigarettes as a harm reduction strategy. But what about EVALI and the risk of death? SIEGEL: I don’t know of any cases of respiratory failure that have been reported in the U.K. How can that be? Today on Freakonomics Radio, a tale of two public-health initiatives. One that leans towards abstinence: MURTHY: We don’t have the luxury, I think right now, of trying to parse which flavors might be okay, which may not be okay. The other, harm reduction: Dorothy HATSUKAMI: It certainly beats 7,000 chemicals that you get from cigarettes. What’s known — and not known — about vaping. * * * Before there were e-cigarettes, there were cigarettes. Just how popular were cigarettes? In the 1950s, 45 percent of adult Americans said they smoked — and that’s a self-reported number, so the actual number may have been even higher. Back then, cigarette ads were still allowed on TV. Vintage Camel Cigarette Jingle: How mild, how mild, how mild can a cigarette be? Make the Camel 30-day test, and you’ll see. Cigarettes had some influential endorsers. Vintage Camel Cigarette Advertisement: According to this repeated nationwide survey, more doctors smoke Camels than any other cigarette. They made smoking sound pretty darned good. Vintage Chesterfield Cigarette Advertisement: The doctor reports no adverse effects for the nose, throat, or sinuses from smoking Chesterfields. Now, don’t you want to try a cigarette with a record like this? But eventually, a mountain of scientific evidence emerged — much of which had been suppressed by cigarette companies — showing that cigarette smoking greatly increases the risk for a number of cancers as well as cardiovascular disease, stroke, and other bad outcomes. In many countries, smoking is still incredibly common. According to the World Health Organization, 76 percent of adult men in Indonesia still smoke cigarettes; in Russia, it’s 59 percent; in China, 47 percent. But in other countries, the smoking rate has fallen steeply and continues to fall. In the U.S. and the U.K., for instance, only about 20 percent of adult males now smoke. This decline is considered one of the greatest public-health victories of all time. How did it happen? Jonathan GRUBER: So, really, the sort of first shock to the system was the spread of information that smoking is bad for you, which caused a big drop in smoking, but mostly among the well-educated. That’s Jonathan Gruber, a health care economist at M.I.T. GRUBER: If you look at smoking rates by education group, it fell precipitously for the most educated and much more slowly for the least educated. Beyond the information channel, there were regulations that l
A recent outbreak of illness and death has gotten everyone’s attention — including late-to-the-game regulators. But would a ban on e-cigarettes do more harm than good? We smoke out the facts.
Listen and subscribe to our podcast at Apple Podcasts, Stitcher, or elsewhere. Below is a transcript of the episode, edited for readability. For more information on the people and ideas in the episode, see the links at the bottom of this post.
* * *
Unless you’ve been hibernating, you’ve probably been hearing about the dangers posed by e-cigarettes and vaping.
CBS News: Two more people have died from vaping-related illnesses, this time in Minnesota. This brings the nationwide toll to 31 deaths across 22 states.
Good Morning America: Public health officials report there are nearly 1,300 probable or confirmed injuries related to vaping in 49 states.
These cases involve a severe respiratory ailment that’s been labeled EVALI, or “e-cigarette, or vaping, product-use-associated lung injury.” Doctors in Detroit recently performed double lung-transplant surgery on one EVALI victim. Even though people have been vaping for years, the deaths are new, and the news has been met with something between alarm and panic.
PBS NewsHour: The Federal Government today warned Americans not to use e-cigarettes following several mysterious deaths linked to vaping.
Vivek MURTHY: I think that when it comes to especially the health of our children, we cannot afford to take risks.
That is former U.S. Surgeon General Vivek Murthy.
MURTHY: And already millions of children are using e-cigarettes who should have never been exposed to these devices.
But while the U.S. is trying to beat back the tide of vaping, there’s another country that’s been encouraging it.
Michael SIEGEL: In the U.K., they’ve actually embraced electronic cigarettes as a harm reduction strategy.
But what about EVALI and the risk of death?
SIEGEL: I don’t know of any cases of respiratory failure that have been reported in the U.K.
How can that be? Today on Freakonomics Radio, a tale of two public-health initiatives. One that leans towards abstinence:
MURTHY: We don’t have the luxury, I think right now, of trying to parse which flavors might be okay, which may not be okay.
The other, harm reduction:
Dorothy HATSUKAMI: It certainly beats 7,000 chemicals that you get from cigarettes.
What’s known — and not known — about vaping.
* * *
Before there were e-cigarettes, there were cigarettes. Just how popular were cigarettes? In the 1950s, 45 percent of adult Americans said they smoked — and that’s a self-reported number, so the actual number may have been even higher. Back then, cigarette ads were still allowed on TV.
Vintage Camel Cigarette Jingle: How mild, how mild, how mild can a cigarette be? Make the Camel 30-day test, and you’ll see.
Cigarettes had some influential endorsers.
Vintage Camel Cigarette Advertisement: According to this repeated nationwide survey, more doctors smoke Camels than any other cigarette.
They made smoking sound pretty darned good.
Vintage Chesterfield Cigarette Advertisement: The doctor reports no adverse effects for the nose, throat, or sinuses from smoking Chesterfields. Now, don’t you want to try a cigarette with a record like this?
But eventually, a mountain of scientific evidence emerged — much of which had been suppressed by cigarette companies — showing that cigarette smoking greatly increases the risk for a number of cancers as well as cardiovascular disease, stroke, and other bad outcomes. In many countries, smoking is still incredibly common. According to the World Health Organization, 76 percent of adult men in Indonesia still smoke cigarettes; in Russia, it’s 59 percent; in China, 47 percent. But in other countries, the smoking rate has fallen steeply and continues to fall. In the U.S. and the U.K., for instance, only about 20 percent of adult males now smoke. This decline is considered one of the greatest public-health victories of all time. How did it happen?
Jonathan GRUBER: So, really, the sort of first shock to the system was the spread of information that smoking is bad for you, which caused a big drop in smoking, but mostly among the well-educated.
That’s Jonathan Gruber, a health care economist at M.I.T.
GRUBER: If you look at smoking rates by education group, it fell precipitously for the most educated and much more slowly for the least educated.
Beyond the information channel, there were regulations that led to much higher prices and taxes. And that, Gruber says, especially helped drive down smoking among younger people.
GRUBER: We have lots of evidence that youths are extra-sensitive to price, which sort of makes sense, right? Youths don’t have a lot of money.
In the late 1990’s, more than 35 percent of American high-schoolers smoked; today, that figure is less than 10 percent. That said, cigarette smoking in the U.S., as in many other countries, remains the leading cause of preventable death. The Centers for Disease Control attributes 1 of 5 American deaths to smoking. That’s nearly half a million deaths per year, or 1,300 people a day. If you add up all the people who die from alcohol and illegal drugs and car accidents and suicide and murder — those are still outnumbered by smoking deaths. How can this be? How can something so demonstrably dangerous be voluntarily consumed by so many people? In a word, nicotine, the stimulant found in the leaf of the tobacco plant.
HATSUKAMI: What nicotine does is, it targets neural receptors in the brain.
That’s Dorothy Hatsukami, a psychiatry professor at the University of Minnesota. She’s a prominent voice in cancer prevention and a member of several national scientific-advisory boards dealing with tobacco use and other drug abuse.
HATSUKAMI: Targeting those neural receptors leads to the release of a number of chemicals in the brain, and these chemicals affect mood as well as cognition. And it also actually makes people want to seek more nicotine.
In other words, nicotine is highly addictive. The craving for nicotine has helped shape civilization. The tobacco plant, thought to be native to the Americas, has been smoked or chewed for at least 2,000 years, often tied to religious or cultural ceremonies. European explorers to America brought tobacco back home in the 16th century, and its use spread quickly. This demand led to massive tobacco plantations back in America, which in turn fed the demand for slave labor. Much of the early American economy was organized around tobacco; it was even used as currency. But here’s the thing: nicotine, tobacco’s most valuable component, the ingredient that makes it so hard to quit smoking — nicotine is not the biggest villain of this story.
HATSUKAMI: What is problematic is that nicotine is delivered in a really dirty delivery system, and that’s the cigarette, which contains a number of toxicants.
HATSUKAMI: Nicotine is not harmless, by any means. Nicotine causes addiction. It has negative effects on a fetus. It might increase the risk factors for cardiovascular disease, and also it apparently does affect the developing brain. But it’s certainly not the most harmful constituent in a tobacco product.
Nicotine also has some proven benefits.
HATSUKAMI: Yeah, certainly nicotine might have some beneficial effects on cognition. And it can help sustain attention, for example.
It may go even beyond that. Paul Newhouse, a psychiatry professor at Vanderbilt, told us a few years ago that nicotine therapy may prove useful for a number of ailments.
Paul NEWHOUSE in a previous Freakonomics Radio episode: Things like memory-loss disorders, Alzheimer’s disease. We’ve looked at ADHD. Other investigators have looked at everything from Tourette’s Syndrome to anxiety disorders to depression. I think that the full potential of nicotine and nicotinic drugs is really not even fully known yet.
Others are not so hopeful.
Robert WEST: I think the potential benefits of nicotine are at best controversial, to be honest.
Robert West is a professor of health psychology at University College London and editor of the journal Addiction.
WEST: There was a lot of research back in the 80’s and 70’s around the idea that nicotine might help with concentration and be a cognitive enhancer. But that kind of research didn’t really bear fruit. Whether it’s helpful in other conditions — I mean some people have suggested Parkinson’s — I think is moot, to be quite honest. Even if it were beneficial, I doubt very much whether it would be as effective as the other treatments we already have.
HATSUKAMI: Well, there probably isn’t as much known about that area as we would like.
What is known about nicotine is this: it is so desirable, so addictive, that millions upon millions of people are willing to inhale cigarette smoke — including the lead, arsenic, ammonia, and benzene — in order to get the nicotine. Not that they necessarily want to: roughly 70 percent of U.S. adult smokers say they want to quit smoking.
HATSUKAMI: So one of the goals, then, is to actually try to reduce the addiction to these highly toxic products and really shift smokers over to less-harmful products.
Less-harmful nicotine products have been around for years: gum and patches and nasal sprays. How effective are they? Not very. One analysis found that just 14 percent of smokers are able to quit when they use one method of nicotine-replacement therapy. The number increases to 17 percent when using, say, a nicotine patch and gum at the same time.
HATSUKAMI: So one of the problems with the smoking-cessation pharmacological tools is that they are unappealing. They don’t have some of the sensory effects that people like when they’re smoking their cigarettes.
How about a vaccine against nicotine addiction? That is something Hatsukami worked on for years. In the early, proof-of-concept study, the results were promising. But ultimately came a large clinical trial.
HATSUKAMI: The results from this phase 3 clinical trial, they were not positive. So that was unfortunate, but that’s not to say that the nicotine vaccine is a bad idea. I think it just needs to be developed further.
So for years, that’s where things stood. Millions and millions of smokers, most of whom didn’t want to smoke but couldn’t stop. Nicotine-replacement therapies that weren’t very effective. A vaccine that wasn’t ready. And then, in 2007, a new product came to market. They’ve since come to be called ENDS: electronic nicotine delivery systems — more commonly known e-cigarettes.
SIEGEL: When e-cigarettes first came on the market, my first assumption was that this is just another tobacco-industry ploy that they can say is safer but really isn’t and just gets more people to use tobacco.
That’s Michael Siegel, a physician and professor at the Boston University School of Public Health. He’s been researching tobacco issues for more than 30 years.
SIEGEL: After studying the issue, it became clear to me that this was very different. And the tobacco companies actually weren’t involved at all. They didn’t get into the picture until 2011. And in fact, this was a much safer product and was helping many people to quit smoking.
The earliest e-cigarettes didn’t have good battery life or deliver their nicotine efficiently. But the technology evolved, with hundreds of brands putting out a variety of vaping devices — some of which could be used for vaping other, more entertaining substances. Here’s how the National Institute on Drug Abuse summarizes the genre: “Electronic cigarettes are battery-operated devices that people use to inhale an aerosol, which typically contains nicotine (though not always), flavorings, and other chemicals. They can resemble traditional tobacco cigarettes, cigars, or pipes, or even everyday items like pens or USB memory sticks.” E-cigarettes proved incredibly popular, for a number of reasons.
SIEGEL: There’s physical stimuli. There’s holding a cigarette. There’s feeling the throat hit, seeing the smoke come off. There’s social stimuli — smoking with other people in social settings.
A new word entered the global vocabulary — “vaping,” or ingesting the vaporized content of these devices.
SIEGEL: I think more than anything, what vaping offers to smokers is an identity. You don’t have an identity as a nicotine-patch-user. Nicotine-patch-users don’t get together in groups and have forums and conventions for the weekend, but vapers do.
It wasn’t long before a vaping champion was crowned: Juul Labs, founded in 2015 and headquartered in San Francisco. The Juul e-cigarette was sleek and minimalist and it came in flavors including mango, cucumber, and mint. By 2017, Juul was the U.S. leader in market share, selling one of every three e-cigarettes. By the end of 2018, the company was valued at $38 billion, and it sold off a 35 percent stake to Altria, the tobacco giant previously known as Phillip Morris. Why did Juul become so much more popular than its rivals? Michael Siegel has one answer.
SIEGEL: Juul has a very different nicotine formulation that makes it much more addictive. It’s a nicotine salt. It’s absorbed much more rapidly into the bloodstream. And because of that, it simulates the pattern that you get with a real cigarette. And that is what makes Juuling so addictive.
And how does Juuling, or vaping any nicotine-based e-cigarette, compare to combustible cigarettes when it comes to toxicity? Dorothy Hatsukami again.
HATSUKAMI: Delivering nicotine via the electronic cigarette is far less toxic than the cigarette, but you still have constituents delivered— foreign constituents delivered to the lung.
SIEGEL: In the testing that’s been done on e-cigarette aerosol, in many cases, they find no detectable levels of any unwanted chemicals. In other cases, there are some chemicals, but only a few. And that doesn’t mean that the products are safe. Those chemicals could cause problems if used over the long term. But the toxicological profile of these products indicates that they’re much safer than cigarettes.
HATSUKAMI: It’s not going to be a harmless product, but it certainly beats 7,000 chemicals that you get from cigarettes.
SIEGEL: The strongest evidence that demonstrates how these products are safer are clinical studies that have been done where smokers have switched to e-cigarettes and there’s been a dramatic improvement in their respiratory function, both subjectively through their reported symptoms and objectively through spirometry testing, which has shown improvement in lung function among these now ex-smokers.
And what about the long-term effects of vaping, versus smoking cigarettes? What’s the data there?
SIEGEL: There’s no long-term data, because the products have not been on the market long enough to be able to do mortality studies to show that using e-cigarettes as opposed to cigarettes is going to lower mortality. The fact that we don’t have long-term studies doesn’t mean that it’s not going to save lives. We know it’s going to save lives based on the short-term clinical data that we do have.
So based on the current evidence: e-cigarettes sound like a substantial improvement over cigarettes, at least on some key dimensions. This is the sort of tradeoff known in public-health circles as “harm reduction.” When people engage in risky behavior, there are at least two ways to help. One is to simply point out how risky their behavior is, and encourage them to stop. This is the abstinence approach. Abstinence may look good on paper, and it may seem perfectly logical to a public-health official or a policy maker who’s never been tempted by any risky behavior themselves. But when it comes to something like cigarette smoking and nicotine addiction — as the data have shown — abstinence is a tough sell.
Harm reduction takes a different approach. This means acknowledging that some people are going to engage in risky behavior, and it’ll be a net improvement if you can come up with a less-risky version of that behavior. That’s the idea behind needle exchanges for heroin addicts and free condoms for teenagers. Or putting seat belts in cars rather than banning cars on the grounds that they’re too dangerous. Or getting cigarette smokers to use e-cigarettes instead. To a cancer researcher like Dorothy Hatsukami, this notion did not come easily. What was her original goal?
HATSUKAMI: Well, initially, it was elimination of the use of tobacco products altogether. But because so many people are addicted to the product, then my focus became, well, let’s take a look at harm reduction. If people can’t quit, then let’s think about products that would reduce harm.
If someone like Dorothy Hatsukami could embrace, however reluctantly, e-cigarettes as harm reduction, you’d think it would be a slam dunk for U.S. policy makers. But it wasn’t. In fact, e-cigarettes are currently not allowed to be marketed or promoted as smoking-cessation tools, the way nicotine gum or patches are. Why not? Okay, this is a little complicated but it goes like this: The Food and Drug Administration was only granted jurisdiction over tobacco products, believe it or not, in 2009. E-cigarettes were still relatively new.
Rather than classify them as tobacco products, the FDA classified them as drug-delivery devices — which have much stronger restrictions than cigarettes — and the agency subsequently declared them illegal. The result was that their sale was, essentially, banned. The e-cigarette companies could have pursued approval as a drug-delivery device. Instead, they sued, and won, which led the FDA to reclassify e-cigarettes as tobacco products. This lifted the ban on their sale, but it also meant they couldn’t be promoted as smoking-cessation devices since, according to the FDA, an e-cigarette basically is a cigarette.
Now, this isn’t to say that plenty of smokers didn’t take up vaping; they did. A recent analysis in the Annals of Internal Medicine found that 54 percent of e-cigarette users also smoke regular cigarettes, but that 30 percent of vapers had quit smoking. At least for now. But if you are an e-cigarette company and you can’t market your product as a safer alternative to existing smokers, who might you market to instead? Especially if your product comes in flavors like mint and mango and cucumber?
SIEGEL: Juuling has become quite popular among youth.
That’s right. While adult smokers trying to quit certainly drove the growth of the vaping industry, another demographic was getting hooked at the same time. Vaping usage in the U.S. today is highest among people aged 18 to 24. Again, keep in mind e-cigarettes only came into existence 12 years ago. Roughly 20 percent of high-schoolers now vape regularly — more than double the share that smoke cigarettes. Which means that a lot of them didn’t smoke before e-cigarettes came along.
SIEGEL: There’s no question that a culture of smoking is being replaced by a culture of vaping. There is a very strong negative correlation between the prevalence of cigarette smoking among youth and the prevalence of vaping among youth. And I think that it’s really the youth addiction to nicotine that’s the problem. It’s not vaping itself. It’s the fact that kids are addicted. If you just vape for a couple of years as a high school student or a college student, there’s really not going to be any major adverse health effects. But if you become addicted to vaping and then you end up vaping for many, many years, there could be long-term health effects.
And the vape of choice among young Americans is Juul. Was this intentional on Juul’s behalf? If you go to Juul’s website today, you’ll see its mission is to “improve the lives of the world’s one billion adult smokers by eliminating cigarettes.” Note the words “adult” and “smokers” — that is, people who already smoke cigarettes. So how did Juul become so popular among adolescents who hadn’t previously smoked?
A study from the Stanford School of Medicine analyzed Juul’s early marketing activity, including many tweets that the company had since deleted. The researchers found that, quote, “Juul’s advertising imagery in its first six months on the market was patently youth-oriented. For the next two-and-a-half years it was more muted, but the company’s advertising was widely distributed on social media channels frequented by youth, was amplified by hashtag extensions, and catalyzed by compensated influencers and affiliates.” So, I’m no marketing expert but that sounds pretty intentional. In any case, the sale of Juul’s sweet and fruity vaping devices skyrocketed among young people and drove the company’s valuation into the billions. It would also make Juul the target of angry parents, late-to-the-game regulators, and everyone trying to figure out why dozens of people were suddenly dying from vaping.
* * *
In the U.S., there are two distinct populations of people who use e-cigarettes: older adults, many of whom are trying to give up cigarettes; and young adults and adolescents, many of whom never smoked. Older adults vaping in order to quit smoking could be considered a public-health victory. Younger people taking up vaping is considered a public-health disaster.
MURTHY: There really is no evidence that supports what was a widely shared theory a few years ago, that if these kids are using e-cigarettes, then that’s actually going to prevent them from using regular cigarettes.
That, again, is Vivek Murthy, who served as U.S. Surgeon General under President Obama.
MURTHY: That was an argument that was widely made by the proponents of e-cigarettes several years ago.
But Murthy says there isn’t sufficient evidence for that argument. In other words, even if vaping is less harmful than smoking, vaping might ultimately lead to smoking cigarettes.
MURTHY: The other issue is that even though e-cigarettes are nearly always going to be less harmful than traditional cigarettes — because again, they’re not combusted, and they don’t have the full array of harmful toxins — that doesn’t mean that they’re benign. There are other chemicals in them. And because these were being produced and sold with so little oversight and regulation, we actually didn’t know, and still don’t know, in many cases, what is in these products.
DUBNER: Why has there been so little oversight and regulation?
MURTHY: I don’t a hundred percent know why, but I do think it’s been way too slow. I do think that we have not done the job we need to do as a federal government. And already millions of children are using e-cigarettes who should have never been exposed to these devices.
DUBNER: So the British government took pretty much exactly the opposite approach of the U.S. Federal Government. And they basically looked at it years ago and said e-cigarettes are probably not the greatest thing in the world for people, but we believe that as a substitute for smoking, they could save a lot of lives. And the British government and their cancer and anti-smoking institutions offer evidence to argue that they have been correct.
MURTHY: Yeah. So the U.K. did take a different approach in some ways. They were more bullish on the prospect of e-cigarettes being helpful for cessation. But the U.K. was also very concerned about protecting children. And they actually took more regulatory measures — including limiting the amount of nicotine in e-cigarette products — which are things that we did not do here in the United States. They tried to go at the problem more with a scalpel as opposed to with a blunt instrument. And I think we struggled with that here in the United States.
SIEGEL: Yeah, the U.K. has a very different approach to electronic cigarettes than we do in the U.S.
That, again, is Michael Siegel, the Boston University tobacco researcher.
SIEGEL: And that is that the U.K. has regulated these products. And most importantly, there is a limit on the amount of nicotine that’s allowable. You can only have up to 20 milligrams per milliliter of nicotine in your e-liquids. In the U.S., there’s no limit at all. So Juul comes along, they put 54 milligrams per milliliter in their product, and it’s no surprise that kids are getting addicted. People may not realize this, but there is Juul in the U.K., but they don’t have a youth Juuling problem. And the reason for that is you don’t have Juul at 54 milligrams per milliliter, you have Juul at 17. In this country, these products have not been embraced for harm reduction, but they’ve actually embraced electronic cigarettes as a harm reduction strategy. And as a result, the health care costs in the U.K. are going down.
Why have the two countries approached the issue so differently? Here’s how Michael Siegel sees it. In the U.S., he says:
SIEGEL: There’s a huge stigma attached to smoking, and people who smoke have much less political power, so it’s very easy to dismiss their concerns. In the U.K., I don’t think that demonization has occurred. There’s a lot less of this kind of prohibitionist or puritanical view of vices that we have here. There’s a lot more concern about smokers and trying to find ways to get them to improve their health and save their lives.
And, as a result:
SIEGEL: The U.K. has not had as much of a problem with youth vaping as we have. There are youth who vape, but the rates are not nearly as high and they don’t have a lot of youth who are addicted.
When Siegel says the British youth vaping rates are “not nearly as high” — well, he is not exaggerating: according to Public Health England, fewer than two percent of Britons under age 18 use e-cigarettes at least weekly, the vast majority of whom smoke cigarettes as well. Among young people who don’t smoke, vaping is almost nonexistent.
SIEGEL: So I think that the lesson we need to learn is that you don’t succeed when you have a popular product by banning it. What works is regulating the product. And I think had the FDA been regulating e-cigarettes from the beginning, had they set safety standards, including maximum nicotine levels, we would never have gotten into this mess. Juul could never have occurred because it wouldn’t have been allowed to come on the market with that high-end nicotine level.
So Michael Siegel’s argument is pretty interesting: public-health officials in the U.K. developed a regulatory plan for e-cigarettes that was meant to maximize smoking cessation among adults while limiting youth uptake. In the U.S., meanwhile, an early attempt at a ban led to a murky regulatory environment that didn’t further either those goals. It also left a company like Juul free to make and market a product that many people now agree is too powerful and too popular with too many young people. But the lack of regulation around vaping did more than just that. It also paved the way for a public-health tragedy that seemed to come out of nowhere.
CBS News: A fourth death has been reported from a severe lung illness linked to vaping.
CBS News: This brings the nationwide toll to 31 deaths across 22 states.
Actually, as of this recording, the death total is 42, with more than 2,000 injuries, across nearly every state, all attributed to EVALI — “e-cigarette, or vaping, product-use-associated lung injury.” The condition involves chest pain, shortness of breath, and vomiting; and it’s been overwhelmingly concentrated among young people — nearly 8 in 10 were under 35.
CBS News: Health officials believe some chemicals found in e-cigarette and marijuana vaping products are to blame, but they’ve not identified any single device, product, or substance that’s responsible.
And because no single device or product was identified, all vaping products were lumped in together as possible culprits — all the different designs and devices and flavors, including the e-cigarettes thought to be the safest. You couldn’t blame people for panicking.
PBS NewsHour: The Federal Government today warned Americans not to use e-cigarettes following several mysterious deaths linked to vaping.
Michael Siegel again:
SIEGEL: The state of Massachusetts enacted an emergency ban of the sale of all vaping products. There are several other states that have enacted an emergency ban on just flavored e-liquids.
Juul came under particularly intense pressure. Its valuation plummeted, its CEO resigned, it laid off hundreds of employees — all this as its home city of San Francisco was enacting what amounted to a ban on all e-cigarette sales. “This temporary moratorium wouldn’t be necessary if the Federal Government had done its job,” said San Francisco’s city attorney. “This is a decisive step to help prevent another generation of San Francisco children from becoming addicted to nicotine.” But what about the sudden outbreak of vaping illnesses and deaths — would banning Juul and other e-cigarettes fix that problem? Siegel didn’t think so.
SIEGEL: I think it’s extremely unlikely that any store-bought nicotine-containing e-cigarettes are involved in this outbreak.
Why was he so confident? Well, there were a number of clues — starting with what was happening in the U.K. Which was pretty much nothing.
SIEGEL: So far, I don’t know of any cases of respiratory failure that have been reported in the U.K. And that’s important because it tells us that it can’t be traditional e-cigarettes because those products have been sold in the U.K. and in other countries for a decade or more, and they haven’t had any problems. Something different is going on here.
So what was going on here?
SIEGEL: I think what is going on different is that we have a huge black market, especially for THC products. And I think it’s those products that are predominantly responsible for the outbreak.
THC, if you don’t remember from chemistry class, is the primary psychoactive ingredient of cannabis. And the Centers for Disease Control, in surveying the victims of the EVALI outbreak, had learned—
SIEGEL: The CDC has reported that approximately 89 percent of the cases are attributable to THC or black-market vaping oils, whereas 11 percent of the cases did not admit to using THC. Now that doesn’t mean that those cases were necessarily attributable to nicotine e-liquids, for a number of reasons. The most important of which is that people tend to underreport their marijuana use, especially youth.
In other words, it seemed these vaping deaths and injuries weren’t primarily being caused by e-cigarettes. Perhaps e-cigarettes had nothing to do with the outbreak. It’s important to note that all e-cigarettes, which are designed to deliver nicotine, are vapes; but not all vapes are e-cigarettes.
SIEGEL: There is a difference between the types of devices that can be used to vape cannabis as opposed to devices that can be used to vape nicotine-based liquids. These are very different types of liquids.
E-cigarettes use liquids that are typically water or alcohol-based, while THC vaping liquids are oils.
SIEGEL: The cannabis distillate really needs an oil base to dissolve properly. You’re basically talking about vaping oil versus vaping water. And the devices that can handle those types of liquids are very different. And we’ve got to be very careful not to conflate the two.
But there was a lot of conflation going on between water or alcohol-based nicotine e-cigarette devices and oil-based vaping devices. Not just in the media reporting on the outbreak, but in how some state governments were approaching e-cigarette bans.
SIEGEL: First of all, the policies I don’t think are justified because there’s no evidence that store-bought nicotine e-liquids are involved at all in this. So why put all these vape shops out of business when it’s not going to have any significant impact in curtailing the outbreak? But secondly, there is going to be some severe negative public-health consequences of these bans. Many ex-smokers who are dependent upon vaping products to stay off tobacco are going to switch to smoking when their products are taken off the shelves.
There are also the hundreds of millions of smokers in places like Indonesia and Russia and China who, if you’re rooting for public health generally, you might want to see have easy access to e-cigarettes. In the midst of all this came a couple of surprising developments. The Trump Administration and the FDA had been leaning toward implementing a ban of most flavored e-cigarettes in the hopes of curtailing youth vaping. But the White House then reversed itself. But Juul Labs, in the face of that expected flavor ban, had already announced that it was discontinuing all its sweet and fruity nicotine cartridges — mango, cucumber, even its most popular, mint, all gone. The only flavors Juul would continue selling in the U.S. are menthol, “Virginia tobacco” and “classic tobacco.” Now, was this a public-health victory? Michael Siegel doesn’t think so.
SIEGEL: I think what a lot of people don’t realize is there is no such thing as an un-flavored e-liquid. Every e-liquid has a flavor, it’s just that tobacco is one of those flavors, and then there’s hundreds of other flavors.
So when the FDA was considering a ban on these flavors — and that ban may still happen, it’s hard to say — what was the idea behind that?
SIEGEL: The idea behind that, presumably, is that youth are more likely to use the non-tobacco flavors than the tobacco flavor. The problem with that is that so are adults. Adult smokers who have quit successfully using these products have predominantly used flavored products, and they specifically don’t like the tobacco product because it reminds them of cigarettes. The whole point of switching to vaping is to get away from the tobacco experience, and so many vapers actually shun the idea of using a tobacco e-liquid. So to take these flavors off the market and to tell smokers, “Okay, well, just go back to the tobacco” — that’s just not going to happen. What are the smokers going to do? They’re basically going to have two choices. Either they just go back to smoking or they try to obtain these products off the black market.
And what about younger vapers who’ve gotten accustomed to — or addicted to — flavored vaping?
SIEGEL: I think a lot of youth are going to transition from flavored e-liquids over to THC oils because those are the products that are going to be available. It’s incredibly easy to get these black-market THC products. You just go onto the internet. You say you’re 21. They will use what’s available. And what’s going to be available is going to transition towards THC oils. And that could actually make the outbreak worse rather than better.
Because the outbreak, remember, the deaths and injuries, seemed to not be driven by e-cigarette use.
SIEGEL: I think the strongest evidence is simply that in 90 percent of the patients admit to using THC, even though there’s a lot of underreporting, testing of the THC cartridges has revealed Vitamin E acetate oil. And so far, not a single nicotine liquid that’s been tested has had any abnormalities in it.
Indeed, in early November, the CDC declared it had identified what it considered a, quote, “very strong culprit” for the vaping deaths and injuries: Vitamin E acetate oil, as Michael Siegel had suspected. What is Vitamin E acetate oil? It’s a thickening ingredient that’s recently begun showing up in vaping liquids — particularly in black-market THC products that are thought to come primarily from China. So, to be clear, as of now it appears that most, if not all, of the deaths and illnesses were caused not by e-cigarettes but rather by sketchy black-market THC products. But in the public interest — and in the pursuit of a policy that seems to be driven more abstinence than harm reduction — state and city governments and some state health departments have already taken steps to curtail the availability of e-cigarettes. What does Michael Siegel think of this?
SIEGEL: I think from the perspective of politicians, this is a really easy way to be able to tell your constituents that you care about kids. You care about health. You are out there banning the flavored e-cigarettes. It’s very easy to do that because there is no opposition. The vaping industry doesn’t have a powerful lobby like the tobacco industry does. And what’s very interesting is that these same politicians who want to ban flavored e-liquids don’t want to touch cigarettes. They don’t want to have any increased restrictions for the sale of tobacco. They don’t want to take tobacco off the shelves. So I think that what they’re doing is basically just finding some way that they can, without having to actually take any kind of politically courageous action, make it look like they’re really taking a strong stance.
From the perspective of health departments I don’t think that they’re being insincere, I think their intentions are to try to improve health, and I’m not questioning that. What I do think is going on with the state health departments, though, is one of two things. I think that a lot of state health departments just take their direction from the CDC. They don’t want to conflict with what CDC says. And there are many health agencies that really have just been against e-cigarettes from the beginning. And they see this as an opportunity to take advantage of this outbreak, to advance their agenda of getting e-cigarettes banned, or at least getting the flavors banned. And in fact, many of the states are doing this through emergency orders, bypassing the legislative process. And the problem with that is it violates the separation of powers.
Health departments do not have the authority to establish law. They’re supposed to enforce the law that the legislature sets out. What they’re doing is declaring an emergency because of the outbreak, and then responding by banning e-cigarettes that don’t have anything to do with the outbreak. I don’t think that there are politics involved in what the state health departments are doing. I think that these are dedicated professionals. I think they’re sincere. I think they’re well-intentioned. But I just think there’s an underlying bias that clouds their thinking.
And how would Michael Siegel, if he left the ivory tower of academia for some big public-health department that was wrestling over the future of e-cigarettes, how would he walk the line between abstinence and harm reduction?
SIEGEL: I think the most important thing that could be done to limit youth access to these products is to restrict the sale of not only e-cigarettes, but all tobacco products, including real cigarettes, to stores that are only open to people who are over 21 years old and that only sell tobacco products or e-cigarettes. Similar to the way we handle liquor in most states in the U.S. I think a second thing that we need to do is to have direct regulations of e-cigarette marketing, and to allow companies to tell the truth to consumers — namely that these are products that are designed for smoking cessation. And I think one of the problems right now is, because companies are not allowed to even inform their consumers truthfully that people are using these products for smoking cessation, they have nothing to fall back on in their ads other than trying to make e-cigarettes or vaping look glamorous.
At the moment, none of it is looking very glamorous.
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Freakonomics Radio is produced by Stitcher and Dubner Productions. This episode was produced by Zack Lapinski, with help from Alvin Melathe. Our staff includes Alison Craiglow, Harry Huggins, Matt Hickey, Greg Rippin, Corinne Wallace, and Daphne Chen. Our intern is Ben Shaiman. Our theme song is “Mr. Fortune,” by the Hitchhikers; all the other music was composed by Luis Guerra. You can subscribe to Freakonomics Radio on Apple Podcasts, Stitcher, or wherever you get your podcasts.
Here’s where you can learn more about the people and ideas in this episode:
- Jonathan Gruber, economist at the Massachusetts Institute of Technology, and director of the National Bureau of Economic Research’s Program on Health Care.
- Dorothy Hatsukami, clinical psychologist at the University of Minnesota, and director of the Tobacco Research Programs.
- Vivek Murthy, physician, and former United States Surgeon General.
- Michael Siegel, physician, and professor of community health sciences at the Boston University School of Public Health.
- Robert West, psychologist at the University College London, editor of the journal Addiction, and director of the Tobacco & Alcohol Research Group.
- “Different Doses, Durations, and Models of Delivery of Nicotine Replacement Therapy for Smoking Cessation,” by Nicola Lindson, Samantha C. Chepkin, Weiyu Ye, Thomas R. Fanshawe, Chris Bullen, and Jamie Harmann-Boyce (Cochrane Database of Systemic Reviews, 2019).
- “JUUL Advertising Over its First Three Years on the Market,” by Robert K. Jackler, Cindy Chau, Brook D. Getachew, Mackenzie M. Whitcomb, Jeffrey Lee-Heidenreich, Alexander M. Bhatt, Sophia H.S. Kim-O’Sullivan, Zachary A. Hoffman, Laurie M. Jackler, and Divya Ramamurthi (Stanford Research into the Impact of Tobacco Advertising, 2019).
- “Toxicological Comparison of Cigarette Smoke and E-Cigarette Aerosol Using a 3D in Vitro Human Respiratory Model,” by Lukasz Czekala, Liam Simms, Matthew Stevenson, Nicole Tschierske, Anna G. Maione, and Tanvir Walele (Regulatory Toxicology and Pharmacology, 2019).
- “Health Effects in COPD Smokers Who Switch to Electronic Cigarettes: a Retrospective-Prospective 3-Year Follow-Up,” by Ricardo Polosa, Jaymin B. Morjaria, Umberto Prosperini, Cristina Russo, Alfio Pennisi, Rosario Puleo, Massimo Caruso, and Pasquale Caponnetto (International Journal of COPD, 2018).
- “Prevalence and Distribution of E-Cigarette Use Among U.S. Adults: Behavioral Risk Factor Surveillance System, 2016,” by Mohammadhassan Mirbolouk, Paniz Charkhchi, Sina Kianoush, Iftekhar Uddin, Olusola A. Orimoloye, Rana Jaber, Aruni Bhatnagar, Emelia J. Benjamin, Michael E. Hall, Andrew P. DeFilippis, Wasim Maziak, Khurram Nasir, and Michael J. Blaha (Annals of Internal Medicine, 2018).
- “Chemical Composition of Aerosol from an E-Cigarette: A Quantitative Comparison with Cigarette Smoke,” by Jennifer Margham, Kevin McAdam, Mark Forster, Chuan Liu, Christopher Wright, Derek Mariner, and Christopher Proctor (Chemical Research in Toxicology, 2016).
- “Inventing Conflicts of Interest: A History of Tobacco Industry Tactics,” by Allan M. Brandt (American Journal of Public Health, 2012).