By Trudy Lieberman
Rural Health News Service

Are e-cigarettes becoming the next public health hazard?
Increasingly, health officials seem to think so, and in early September the Centers for Disease Control and Prevention (CDC) suggested that Americans stop vaping until health officials know more about an epidemic of lung disease that has made some 450 people sick and caused three deaths. A study just published found that more than 80% of the patients said they used tetrahydrocannabinol (THC), the psychoactive ingredient of marijuana, but more than half also used nicotine, the culprit in conventional cigarettes.
Although no one device, product or substance has been linked to all these cases, CDC official Dana Meany-Delman warned, “While this investigation is ongoing, people should consider not using e-cigarette products” and should not buy products off the street or modify them in any way.
There is still much that is not known about e-cigarettes. The New York State Department of Health just identified Vitamin E acetate, an oil found in some marijuana-based vaping products, as the likely cause of the recent outbreak of vaping-related lung disease. But many other questions remain.
Health agencies, regulators, and anti-smoking groups are worried that more Americans — especially teenagers — will be enticed into a long-term smoking habit by the thousands of flavors such as gummy bear, cherry, and cinnamon that make vaping so popular.
A study reported in the British Medical Journal noted that by early 2014 buyers could choose from 466 brands and more than 7,000 unique flavors of e-cigarettes. The newer brands were more likely to claim they were healthier and cheaper than cigarettes and were good substitutes where smoking was banned.
If you tire of gummy bear and cherry, there are always new flavors to hook you to the smoking habit. And that may be what the e-cigarette industry is banking on.
With such a yummy edge, it’s not hard to see why these products have become a marketing success story, especially among young people trying tobacco for the first time.
In New York City, where I live, and in my neighborhood near the New York University campus, e-cigarette smoking is so prevalent on the sidewalks it reminds me of the old days when use of old-fashioned cigarettes was in vogue and smokers were everywhere.
“A long and tragic history has taught us that nicotine addiction often begins as a pediatric disease,” former Food and Drug Administration (FDA) Commissioner David Kessler recently wrote in a New York Times op-ed. Kessler was the commissioner in the 1990s and found deficiencies in America’s regulation of tobacco products. Congress eventually gave the FDA authority to regulate both traditional cigarettes and e-cigarettes.
Twenty-five years ago, Kessler’s FDA investigated the tobacco industry to better understand nicotine. He argues that if the co-founder of Juul Labs (the maker of e-cigarettes) is serious that the company has no incentive to see minors use its products as it claims, then it needs to change the e-cigarette’s design, and if it doesn’t, the FDA should reject it as a new product.
Whether the company will make any changes or whether the CDC’s warning will tamp down sales is anyone’s guess right now.
State and local governments are also pushing back. More than 200 jurisdictions have put limits on selling flavored e-cigarettes. Several states have raised the age at which tobacco products can be purchased. The aim, of course, is to discourage teen vaping.
A newly enacted San Francisco city ordinance bans all sales of e-cigarettes, including online purchases delivered to city addresses, until the products go through an FDA review.
Juul seems to want it both ways. It is supporting efforts to raise the minimum age to buy its products but is fighting local laws to curb the marketing of such products, including the flavored e-cigarettes. In San Francisco, it is financing a proposed ballot initiative that would push back the city’s ban. It’s also proposing a new system that would continue to allow vaping products on the market.
It has been sponsoring full-page newspaper ads that present a good-guy image for the public — like the ad that says the company is cracking down on underage sales with its 2,000 secret shoppers keeping tabs on retailers.
In the meantime, let’s hope the CDC’s latest warning about e-cigarettes will carry the same weight as the warning from Dr. Luther Terry, the U.S. surgeon general in 1964, whose ground-breaking report linked tobacco use to lung cancer and heart disease and dissuaded millions of Americans from ever smoking.
How should e-cigarettes be regulated? Write to Trudy at [email protected].
Editor’s note: Around the time the article was written, CBS News reported that Juul CEO Kevin Burns told the news outlet, “Don’t start using nicotine if you don’t have a preexisting relationship with nicotine. Don’t use the product. You’re not our target consumer.” Burns also said in the interview, “I can’t imagine we had the data to support that we’re selling a product that is damaging to the American public and we had that data that we’d continue to sell that product.”