Friday, October 11, 2019

Age Counts: Who Vapes (Tobacco/Nicotine) and Who Gets Lung Injuries

Federal officials, most notably at the Centers for Disease Control and Prevention, continue to be remarkably vague about the cause of 1,299 acute lung disease injuries and 26 deaths among people who have vaped.  This ambiguity, which I believe is out of sync with normal CDC investigations, has led to a media frenzy and partial or full bans on e-cigarette sales in many localities.  Major retailers are scrapping e-cigarettes while continuing to sell cigarettes, which have killed 368,000 smokers already this year. Making vastly safer cigarette substitutes unavailable to 8 million adult vapers will inevitably increase cigarette consumption, driving the death count even higher.

Officials have disclosed few details about the lung injuries and deaths.  On October 10, the CDC posted a report, once again highlighting “e-cigarettes, or vaping products” in the title while relegating critically important information about contaminated marijuana products to the fine print.

CDC’s data on 1,043 cases confirmed that the injuries are concentrated among younger age groups.  If nicotine vaping was the cause, the age distribution of lung injuries would be similar to the age distribution of vapers.  I used the tobacco questions in the 2018 National Health Interview Survey and in the 2018 National Youth Tobacco Survey to generate estimates of the number of current adult and underage vapers (here).  The table shows the distribution of lung injuries compared with the distribution of current (tobacco/nicotine) vapers.

Age Distribution of Lung Injury Cases and Current Vapers
Age (years)Lung Injury Cases* Percent (number)Current Vapers** Percent (millions)

Less than 1815% (156)8% (0.7)
18 to 2021% (219)11% (1.0)
21 to 2418% (188)14% (1.2)
25 to 3426% (271)27% (2.4)
35+20% (209)40% (3.5)

All100% (1,043)100% (8.8)

**Based on tobacco questions in the 2018 NHIS (18+ years, vaping every day or some days) and 2018 NYTS (< 18 years, vaping 20-30 days in past month)

The table reveals starkly different age distributions.  While 36% of lung injuries affected those under 20 years, that group constitutes only 19% of all current vapers.  Forty percent of the 8.8 million current vapers were over age 35, compared with only 20% of lung injury patients. 

The table underscores another striking comparison.  The main rationale for punitive action against e-cigarette retailers is the so-called teen vaping epidemic, which I have discussed previously (here, here and here).  But federal surveys show that underage teens make up only 8% of the 8.8 million current vapers, or about 736,000 individuals.  Of those, about 59% (430,000) are current cigarette and/or cigar users.  

Here’s the tradeoff: 92% of current U.S. vapers are adults, most of whom are either current or former smokers (here).  Federal and state actions that prohibit vape products to “save the children” will predominantly and permanently injure their smoking parents and grandparents who are desperate to stop.

In summary, the age distribution of lung injury cases is considerably different than that of vapers, with injuries weighted toward the younger cohort.  This supports the emerging evidence that the outbreak is not related to commercial e-cigarettes and vape products, but rather to black market offerings.  Importantly, the misdirected campaign against the former threatens to disrupt availability to adult vapers, who desperately need them.

Monday, October 7, 2019

CDC Recognizes THC in Lung Injury Outbreak, But Teen Marijuana Use Ignored

The Centers for Disease Control and Prevention finally acknowledged on September 27 that contaminated liquids containing tetrahydrocannabinol (THC) and cannabinoid (CBD) oils are the likely cause of the recent outbreak of lung injuries.  The agency said that “Most patients report a history of using THC-containing products. The latest national and regional findings suggest products containing THC play a role in the outbreak.” As of October 1, there were 1,080 cases and 18 deaths. 

Unfortunately, the lung injuries and deaths have been conflated with the so-called teen vaping epidemic, which I have put into perspective in this blog (here, here, here and here).  Federal officials, however, continue to ignore one critical link: teen marijuana use.  Government surveys document that the prevalence of current (past 30 days) marijuana use has been high among high schoolers for 25 years.  The link is further demonstrated in the 2018 National Youth Tobacco Survey.  Although officials portray current high school vapers as caught up in a tobacco/nicotine epidemic, they rarely acknowledged that the students had vaped marijuana, as shown in the chart that I presented on September 25 at the Global Tobacco and Nicotine Forum in Washington, DC.  Of the 3.1 million high school vapers in 2018, over half had vaped marijuana.  The more teens vaped, the more likely they had used marijuana.  It is therefore not surprising that 16% of the lung injuries occurred in high schoolers.

Although the new CDC statement about THC is helpful, it over-emphasizes e-cigarettes, and it came weeks after state health authorities and the FDA implicated illicit liquids related to marijuana.  The CDC’s slow-walking and its continued conflation of e-cigarette use and nicotine vaping have had significant consequences. 

First, officials have eroded the commitment of vapers who quit smoking, which may lead them to return to smoking.  Second, the CDC is discouraging current smokers from switching to e-cigarettes, even though such products have been used by millions of consumers nationwide for over a decade with no acute lung injuries.  Third, the CDC failed to warn consumers about using illicit THC liquids.  Earlier, more detailed warnings from the CDC might have save lives and limited injuries.

The vaping-related injuries and deaths are clearly tragic, but so are the deaths from smoking: nearly a half million annually for the past 30+ years, or more than 1,300 every single day.

Thursday, October 3, 2019

A False Connection Between E-Cigarettes and Heart Attacks

The Journal of the American Heart Association on June 5, 2019, published an article, “Electronic cigarette use and myocardial infarction among adults in the US Population Assessment of Tobacco and Health [PATH],” by Dharma N. Bhatta and Stanton A. Glantz (here).  In reading the article, I discovered that the authors misrepresented the research record;  presented a grossly inaccurate analysis of PATH Wave 1 survey data, and omitted critical information with respect to (a) when survey participants were first told that they had a heart attack, and (b) when participants first started using e-cigarettes.  The article reflected a significant departure from accepted research practices. 

The authors reported that current e-cigarette users were twice as likely as never users to have had a heart attack, based on information from 38 survey participants.  They reported odds ratios (ORs) of 2.25 (95% confidence interval, CI = 1.23 – 4.11) for 19 daily vapers, and 1.99 (CI = 1.11 – 3.58) for 19 some-day users (Abstract, Table 3 and Table S6).  Drs. Bhatta and Glantz claimed that their study confirmed that “e-cigarette use is an independent risk factor for having had a myocardial infarction…”  In a blog post on the University of California San Francisco website, Dr. Glantz cited the study as “more evidence that e-cigs cause heart attacks” (here).

I have extensive experience conducting research on the PATH data files.  I conducted an analysis of the Public Use Wave 1 data, which has no restrictions on release of results.  I found that at least 11 of the 38 current e-cigarette users were first told that they had a heart attack years before they first started using e-cigarettes. 

My research team conducted further analyses that were discussed in letters we sent to JAHA editors on July 11 and July 18; these letters were never acknowledged.  At the instruction of the Inter-university Consortium for Political and Social Research, I am not able to share those letters with you.