Over the past few months, hundreds of people, many of them young and previously healthy, presented at hospital emergency departments with a mix of symptoms including cough, chest pain, and shortness of breath. Some also had nausea, vomiting, and diarrhea. They complained that they felt weaker, were losing weight, and some developed fevers before coming to medical attention. Their bodies were acting as though they were fighting off a massive lung infection, but doctors didn’t find any bacteria or viruses to blame. The only common thread was that they were all e-cigarette users. While some were older and had other health problems, two-thirds of the patients were previously healthy teenagers and people in their 20s or early 30s.
Many needed supplemental oxygen while at the hospital, still others struggled so much that they had to be on a ventilator to help them breathe. X-rays and other imaging showed major injury and inflammation in the lungs. One of the most worrying aspects was how quickly the illness developed. Problems appeared over a matter of a few days, and many of these people had only been “vaping” for a few months or years.
Their bodies were acting as though they were fighting off a massive lung infection, but doctors didn’t find any bacteria or viruses to blame.
The number of young people who vape has skyrocketed in recent years, and now, in 2019, 3.6 million Americans under 18 use e-cigarettes on a regular basis. The number of high school seniors who vape has doubled in the last year alone. E-cigarettes are much more popular with teenagers than regular cigarettes. In fact, 40% of kids under 18 who vape have never smoked a regular cigarette. As a result there are potentially hundreds of thousands of people now addicted to nicotine who might never have tried it if not for e-cigarettes.
Up until now, e-cigarette users have been in the dark about what they are drawing into their lungs, with the manufacturers and marketers as the only source of information – a situation eerily similar to our relationship with big tobacco 50 years ago. Coincidentally, JUUL is now 35%-owned by Altria (formerly Phillip-Morris), which makes Marlboro cigarettes, the most popular cigarette brand in America.
Vaping appeals to teenagers on many fronts. E-cigarettes don’t leave an odor on clothes, hands, or breath. This makes vaping much easier to hide than traditional cigarettes (or marijuana, which can also be vaped). In fact, e-cigarette cartridges or “pods” that hold nicotine are often indistinguishable from those that hold tetrahydrocannabinol (THC), the chemical in marijuana that gets people high. Additionally, most young people see vaping as less harmful than smoking, and a variety of available flavorings make it very appealing.
Vaporizer companies target a young audience with flavors like bubble gum, watermelon, and cotton candy. Flavorings are the single most important influence on getting young people to start vaping according to the United States Surgeon General, and the federal government may now be considering banning these flavors. Style is a factor, too. Vaporizers are compact, attractive, and some are modeled to resemble flash drives, which makes them even easier to conceal, and adds to the “cool” factor. The explosion in popularity among youth has brought more attention to these companies’ questionable marketing tactics, especially now that people are getting sick.
The major problem with that message is that people confuse “safer” with “safe.”
Years before the explosion in popularity among adolescents, when e-cigarettes first appeared on the market, they were touted as a safer alternative to cigarettes. Frankly, it’s hard to imagine anything more dangerous than cigarettes. They kill over 480,000 Americans every year. That’s more than the annual death tolls from HIV, drugs, alcohol, car accidents, and guns combined. They cause cancer almost anywhere in the body, chronically damage the lungs, and quadruple the risks of stroke and heart disease. Cigarettes do their damage slowly and insidiously, enabling the smoker to be in denial about the health effects. Thanks to decades of anti-smoking campaigns, people are more aware than ever of these dangers, and the percentage of American adults who smoke is at an all-time low of 14%. However, the rapid rise of vaping is a much different story.
Vaporizers have seen an explosion in popularity since they first appeared in the early 2000s. Over the past two years, one company, JUUL, has come to dominate the market. In 2019, roughly 75% of vaporizers sold were JUUL products. JUUL came to the market late, first appearing in 2015, and most of their growth has taken place in the past two years.
JUUL devices came out before the Food and Drug Administration (FDA) started regulating e-cigarettes. In fact, it took until 2016 for the FDA to prohibit sales of e-cigarettes to people under age 18. Although JUUL touts its product as a safer option for smokers to switch to, many JUUL and other e-cigarette users started young and were not former smokers. More than half of current vape users started under the age of 18, and almost as many first experimented with vaping because their friends did it. Kids under 18 are the fastest growing user group and are much more likely than adults to start vaping. In 2018 alone, 1.5 million kids under 18 started using vaporizers. As a result, millions of minors vape, and the FDA has been slow to react to the growing crisis. It wasn’t until this September 2019 that the FDA warned JUUL that it was breaking the law by advertising vaping as safer than smoking. But the message is already out there.
The major problem with that message is that people confuse “safer” with “safe.” A quarter of teenagers and young adults who vape cite this as a reason. The current rash of vaping-related illnesses includes 805 hospitalizations and 12 deaths so far, with almost half of those appearing in the past two weeks. Although this is nowhere near the hundreds of thousands killed every year by regular cigarettes, it suggests that there is a lurking danger. Up until a few weeks ago, the Centers for Disease Control and Prevention (CDC) advised current cigarette smokers that they may benefit by switching to e-cigarettes. The CDC still recommends that people who used vaping as a means to quit smoking should not switch back to regular cigarettes, but at the same time it also urges people to avoid vaping altogether.
Regular cigarette smoke contains thousands of chemicals including carbon monoxide, cyanide, arsenic, formaldehyde, lead, and tar. Because nothing is burned in an e-cigarette, many of these poisonous and cancer-causing agents are not present, one reason people believed vaping would be so much safer than smoking.
Now that people are getting sick – especially young adults who had been healthy before vaping, the public is demanding answers. Unfortunately, the FDA does not require e-cigarette manufacturers to tell consumers exactly what is in the so-called “vape juice.” Only after several hundred people have gotten sick are government agencies like the CDC and FDA beginning to analyze these liquids and the vapor produced by these devices. Up until now, e-cigarette users have been in the dark about what they are drawing into their lungs, with the manufacturers and marketers as the only source of information – a situation eerily similar to our relationship with big tobacco 50 years ago. Coincidentally, JUUL is now 35%-owned by Altria (formerly Phillip-Morris), which makes Marlboro cigarettes, the most popular cigarette brand in America.
Propylene glycol, a food additive and the source of fake smoke in those fog machines you might have seen at a concert, is the main component of the liquid used in e-cigarettes and the source of the visible vapor they produce. Newer, more powerful vaporizers can transform some of the propylene glycol into formaldehyde (a cancer-causing toxin), and acrolein, which is damaging to the heart and blood vessels. Both of these chemicals are also present in regular cigarettes.
Doctors and other scientists analyzing the recent illness outbreak have identified several other possible culprits, including vitamin E acetate, acetals, aldehydes, and diacetyl. Vitamin E acetate is a liquid form of vitamin E, which in normal amounts is harmless and even healthy to eat, but damaging to the lungs when inhaled. Acetals and aldehydes are chemicals found in the flavorings of vapor liquid that can cause lung inflammation and interfere with the body’s normal immune system function. Diacetyl has been found in dozens of vapor flavorings and is known to damage the smallest parts of the airways, leading to a disease called bronchiolitis obliterans or “popcorn lung,” (a nickname given to the condition because it was first seen in workers packaging microwave popcorn).
Over three quarters of those who got sick in the recent wave of illnesses reported vaping THC products. Many used nicotine as well, but a full third reported using THC exclusively, and 16% vaped only nicotine and no THC.
Investigators wanting to know if the vaping liquid itself, without nicotine or THC, posed any risks. A study looking at the physical effects of vaping without nicotine found that it decreased blood pumped by the heart, lowered blood oxygen levels, and reduced blood flow through arteries. All of these changes were immediate and easily measurable, even in people who had never vaped before. With all the potential poisons in vaping liquid, it is no wonder that, even when nicotine is removed, e-cigarettes have immediate, negative health consequences.
But even if the liquid itself were safe, it does contains nicotine. After all, it is ultimately the nicotine that gets users hooked and keeps them coming back for more. Highly addictive, nicotine is absorbed into the bloodstream through the many vessels in the lungs. It quickly activates receptors in the brain causing a release of dopamine. Dopamine is the neurotransmitter associated with pleasure and reward. Each puff or drag on a cigarette or vaporizer delivers another hit of dopamine. This basically trains the user to keep wanting – and getting more. Once addicted it can be extremely difficult to stop. Nicotine increases blood pressure and heart rate immediately after smoking or vaping. In the long term, nicotine puts people at higher risk of some cancers and suppresses the immune system. Diabetes, acid reflux, chronic kidney disease, early eyesight problems, reproductive issues in women, and erectile dysfunction in men are all known to be associated with chronic nicotine use. Nicotine has detrimental effects on the developing teenage brain. It slows brain development, negatively changes how people learn, and may reduce attention span. Using an addictive drug like nicotine as an adolescent can make it harder to quit as an adult and make other addictions more likely.
This story is still developing, and there will undoubtedly be more information and answers to come. But there is no doubt now that vaping is not harmless. Additionally, our country now risks having a whole new generation addicted to nicotine. More people will get sick, and more may die as this new man-made epidemic rages on. Even with the hindsight from the past 70 years of fighting big tobacco companies, our government has been slow to react to this crisis. The FDA has made some moves, but it may be too little too late. Although authorities have several suspects for what’s causing the rash of illnesses, the CDC still maintains that no single ingredient or product is linked to all the cases. For now, the best course of action is to avoid vaping entirely.