Safer Solutions: Clearing the Air Around Vaping-Related Lung Injuries
In 2019, a rash of mysterious lung illnesses appeared around the country. That summer, 14 states reported cases of vaping-related lung injuries—and tragically, even deaths. Hospitalizations peaked in late September 2019 and subsided by February 2020. The illness was soon named “e-cigarette or vaping product use-associated lung injury” (EVALI).
What happened next presents a case study on the long shadow misinformation can cast on public health and public policy.
If adults cannot quit smoking outright, switching exclusively to reduced-risk products like e-cigarettes can improve their health. But what happens if that factual information is clouded by a false narrative? In this case, persistent misunderstanding of what causes EVALI continues to hinder Americans’ access to accurate information and tools to better their health.
As always, when we write about nicotine and tobacco, we have to set some baseline facts, many of which are not broadly known among the American public and health professionals:
- Lighting tobacco on fire is what makes smoking deadly. Tobacco smoke contains thousands of chemicals, some of which cause cancer and other diseases, and nearly half a million Americans die from smoking-related diseases every year.
- Nicotine is a well-known chemical found in tobacco. It has addictive properties, but it is not the chemical that kills people who smoke cigarettes. That is why we see Food and Drug Administration-approved products like nicotine patches, lozenges, and gums to help people quit smoking.
Back to EVALI. As often happens with a sudden new illness, it took months for researchers to determine the true cause of these lung injuries. Assumptions and headlines filled the gaps during those months of uncertainty. Many patients were young and reported vaping, and a “youth vaping epidemic” had recently been declared, leading many doctors, politicians, and journalists to point the finger at nicotine vaping.
What researchers eventually found was that EVALI was indeed driven by vape use, but not by nicotine vaping. The injuries were linked to vaping illicit tetrahydrocannabinol (THC), specifically where black-market manufacturers and home mixers had added a chemical called Vitamin E acetate to THC vape liquid. Vitamin E acetate is often found in cosmetics, and while it is considered safe when applied to the skin, it is dangerous when inhaled.
In short, an additive in illicit THC products is what drove the injuries and deaths associated with EVALI. As with all prohibitions, banned products are not regulated, leaving them at risk for poor quality controls and the introduction of unsafe ingredients. Interestingly, the first five states to legalize recreational cannabis had very low EVALI rates. In these states, “well-established [THC] markets may have crowded-out use of riskier, informally sourced e-liquids,” according to a researcher from the Yale School of Public Health. None of the states with the highest EVALI rates had legalized or regulated recreational cannabis at the time of the outbreak.
But thanks to the public narrative that took hold, nicotine vapes paid—and are still paying—the reputational price. Even after the cause of EVALI was determined, more Americans wrongly believed that nicotine e-cigarettes are as harmful as (or more harmful than) cigarettes. At the height of EVALI and beyond, some states have taken steps to restrict or ban sales of nicotine vapes, a move the Yale study said “targeted the wrong behavior” if the goal was to reduce EVALI. And years after researchers uncovered the true cause of the illness, statements from public health organizations and news coverage of nicotine vaping still regularly mention EVALI as a risk.
In order to discuss and debate appropriate measures for improving public health, we need a shared set of facts and a shared sense of reality. It is long past time to clear the air of confusion about EVALI so that we can accurately assess the relative risk of nicotine vapes compared to smoking and explore their role in helping some adults who smoke switch to safer behaviors.