When a deadly virus swept the U.S. in 2009, killing thousands of people, panic felt especially necessary. A variant of the influenza that spreads every year, the “swine flu” made headlines as new reports of deaths rolled in. Graphic, tragic tales of lives lost spread fear.
Many Americans still remember that winter as particularly treacherous. But swine flu ultimately did no more damage in the country than any typical flu virus. In fact, the year that swine flu struck was one of the lightest flu seasons in recent history. Influenza killed about 12,500 Americans that year. The average annual death toll over the past decade has been closer to 50,000.
Social scientists have since explained the panic as a matter of “risk acceptability.” What made that flu stand out in people’s minds? In part, who it killed. Unlike in most years, swine flu hospitalized many young adults. Cases involved people who are not supposed to die of the flu—not just the grandparent with emphysema, but the high-school athlete. Despite any ongoing plague of death and destruction, this sort of new, unanticipated danger invariably captures national attention.
Anxiety is a powerful motivator, but by definition it exists around risks that are not deemed acceptable. Anxiety can mobilize people to swift and decisive action, of the sort no longer considered for more dangerous threats that society does accept. Smoking tobacco, for instance, kills some 480,000 Americans every year. But it does so gradually with cancers and heart disease that strike after decades of use. The annual death toll is now so expected that it does not constitute news. Similarly accepted are the fatal effects of inhaling chemicals in air pollution, which kills about 7 million people around the world annually.
At the moment, the leading public-health issue in the news is vaping. Push alerts mark incremental tallies in people hospitalized with serious respiratory illnesses related to vaping. So far this year the number is 805—with a median age of 23—according to a widely discussed report released by the Centers for Disease Control and Prevention last week. The week prior, 530 hospitalizations had been reported. The number of deaths related to vaping has grown to 12.
In September, President Donald Trump announced a commitment to ending the vaping scourge: “We can’t allow people to get sick, and we can’t have our youth be so affected.” In addition to the youth of the victims, uncertainty about exactly what’s causing this spike in sickness has fueled an emotional public response. A mix of political momentum and genuine will to protect kids has led to calls for bans and absolute avoidance of vapes. Massachusetts temporarily banned the sale of all vaping products. Walmart announced it would stop selling all vaping products. California allocated $20 million for a “vaping-awareness campaign.”
There appears to be a unanimous consensus that something should be done to better understand and prevent this vaping-related harm. The message from many in the public-health community simply has been to avoid vaping. Last week the CDC told Americans as much. But as bans are actually being implemented, some experts are realizing the potentially dangerous effects of misplacing collective anxiety.
“What we’ve seen in the past several months is unique,” says Brian King, the CDC’s deputy director for research translation on smoking and health. After the recent, jarring uptick in serious cases of vaping-related lung illness, he has been trying to discern the exact extent of the harm. He believes that the agency is close to having a full accounting. “It’s possible there is an influence of stories in the media—that people may be more likely to report or to suspect vaping was the cause of lung disease,” King says. “Even so, the rates are markedly higher than in past years, so it’s likely something new is going on.”
Abigail Friedman, who studies tobacco use at the Yale School of Public Health, points out that the majority of the most popular vaping products have been on the market for at least a few years. The question is not whether vaping itself is safe or unsafe, she emphasizes, but what elements of the practice are causing these acute diseases: “An e-cigarette is fundamentally a device, not a substance. One thing that I think is really confusing people is that vaping just means using an e-cigarette. It doesn’t tell you what people put in it. You could put water in an e-cigarette, right?”
Vaping water should be a harmless, if curious, thing to do. Adding nicotine to that vapor, on the other hand, noticeably affects the cardiovascular system and brain. The addictive properties of nicotine can alter neural functioning permanently, especially in younger people—that’s why every medical institution advises against vaping. But nicotine alone should not acutely cause the sort of severe inflammatory lung disease that is being seen.
Identifying the actual compounds that are causing people’s lungs to shut down is the real challenge for researchers and doctors. For those unacquainted with vaping, this means the “juice” that’s in the cartridges. These can be filled with anything at all, technically, if not legally. Some people concoct their own juice, or buy it by the gallon and refill old cartridges. Some cartridges are sold legally, and others on the black market. “People are modifying cartridges to accommodate other substances,” King says.
The lung diseases are especially common in people who have vaped THC-containing products, both manufactured and modified. (THC is the primary psychoactive compound in cannabis.) But he says the CDC has not ruled out harms from nicotine-only products. In all cases, some element (or elements) in the liquid is getting into people’s lungs and causing a severe inflammatory reaction. Some have been traced to a vitamin E compound. Other cases have involved vegetable glycerin, a common ingredient in skin-care products. Friedman notes that just because an ingredient is “natural” or is safe to smear on one’s face, or to eat, does not make it safe to inhale.
To broadly condemn vaping for these illnesses may be akin to blaming injections instead of heroin, or coffee cups instead of arsenic-laden coffee. Damage to the lungs is technically a result of a person’s immune system attempting to eradicate the foreign invader. Identifying which compound triggered any given reaction involves the variability of individual immune systems, meaning some people have severe illnesses after inhaling something that others tolerated—like gluten in the bowels of a person with celiac disease. This could make illnesses harder to trace than if the problem were due to a single, universally poisonous contaminant (like bootleggers cutting their THC with cyanide). While regulatory agencies have a general sense of what compounds are safe to eat and drink, there is no such historic repository of wisdom or data on what compounds are safe to vape.
Amid so much uncertainty and harm coming from the mushrooming market for novel, unregulated products, some researchers raise the concern that banning legal vapes would make the problem worse, not better. Some nicotine-addicted people would be driven to the black market. Others could switch from vaping to smoking cigarettes. In a 2015 study, Friedman and colleagues found that vaping bans increased rates of teenage smoking. “Electronic and conventional cigarettes are economic substitutes,” Friedman says. “If the price of one product goes up, demand for a substitute is expected to increase.”
Friedman uses Diet Coke drinkers as an analogy: If Diet Coke were banned, people would likely switch to Coke or Coke Zero or Diet Pepsi, not water. This replacement principle would be especially true for nicotine users, because the substance is even more addictive than Diet Coke.
Sunny Shin, who studies tobacco use at Virginia Commonwealth University, says his colleagues are seeing cases of young people switching to cigarettes because they are scared of vaping, a sort of warped perception of overall harms. “Some e-cigarette companies targeted young people [with marketing], and people in low-income communities, and many in those targeted groups started to think they should avoid smoking because it causes cancer, but they thought vaping was harmless,” Shin says. Now that trend could be reversing, and people who got addicted to nicotine because of marketing by vaping companies stand to suffer yet more if they transition to smoking or vaping homemade products.
For years, vaping products were rolled out with essentially no oversight. Not until 2016 did vaping devices come under the jurisdiction of the Food and Drug Administration. While the big vaping companies face distinct controversies over targeted marketing, flavored products, and drawing countless people into long-term nicotine addiction, mainstream products might be the least likely to be the source of recent spikes in disease.
The most radical solution could also be the most responsible and careful. If you ban it, you can’t regulate it. At least metaphorically speaking, the juice cannot be put back into the cartridge.
“This is a good moment to establish the regulatory structure for these vaping products that should have been in place since the beginning,” Shin says. He emphasizes that ideally no one would be using nicotine regularly, and that the emotional impulsivity that underlies tobacco use is an effective target if a society truly wants to stop people from abusing substances. But short of that sort of meaningful preventive approach, substances can at least be made as safe as possible.
When nicotine is delivered to people’s brains by way of regulated and thoroughly tested products, at least the risks become more predictable. As in the food system, contaminated or especially dangerous products can be traced, and individual products recalled or manufacturing practices banned. This would mean funding the FDA and state health departments to test and ensure the purity and safety of products. It could also involve an industry-driven approach. “You want a device that’s tamper-proof,” Friedman says. “You want a device where people can’t inject vanilla extract, or whatever they have at home to make a flavor, because they can’t buy flavored products.”
As the nebulous long-term health consequences of vaping reveal themselves, it will remain the goal of public health to minimize nicotine use altogether. Doing this will involve the common public-health approach known as harm reduction: working to make a dangerous practice as safe as possible. Drawing on the failures of approaches like abstinence-only sex education and prohibition of alcohol, harm reduction is considered whenever total elimination from society does not seem to be an option. People around the world throughout history have ingested tobacco, and the capitalist American spirit of autonomy has never had the political will to ban it altogether. If the past is any indication, the last humans on Earth will be ingesting tobacco and alcohol as the waters rise around their ankles in their survival bunkers.
In the meantime, the impulse to discontinue all sales and outright ban all vaping products may be a case of applying one big hammer to a job that requires a belt full of small screwdrivers. Meanwhile, in the mission to prevent fatal lung disease, that big hammer could be squarely aimed at cigarettes and air pollution.