Vaping (Marijuana) and Lung Disease: Tale of Two State Health Departments

A few days ago, vaping-related deaths in two states were publicized by their respective state health agencies.  The announcements reflect a stark difference in tone and accuracy.

MICHIGAN

“The Michigan Department of Health and Human Services (MDHHS) [announced] the third death associated with the outbreak of vaping-related lung injuries in the state” on January 10.  Dr. Joneigh Khaldun, MDHHS Chief Medical Executive and Chief Deputy for Health, said “We extend our deepest condolences to the family. I urge people not to use THC-containing e-cigarettes or vaping products until the specific cause of these vaping-related severe lung injuries being reported nationwide has been identified.”  (emphasis added)

MDHHS recommendations start with the following: “People should not use THC-containing e-cigarette or vaping products, particularly from informal sources such as friends, family or in-person or online sellers.” (emphasis added)  The agency says people should avoid vitamin E acetate and “should not add any other substances not intended by the manufacturer to products… Adults using e-cigarettes or vaping products as an alternative to cigarettes should not go back to smoking.”

This is an example of a public health agency providing useful information to marijuana and tobacco users: Don’t vape THC products that are not from legitimate retailers.  Don’t stop vaping legitimate nicotine products and return to smoking.

 

KENTUCKY

On the same day, the Kentucky Department for Public Health “announced the state’s first probable fatality related to vaping.”  Eric Friedlander, acting Secretary of the Cabinet of Health and Family Services, said, “To protect public health, we urge Kentuckians – especially young people -- to stop using all vaping products.” (emphasis added)  Public Health Commissioner Dr. Angela Dearinger added, “health experts can’t guarantee the safety of any e-cigarette or vaping product.”

In its three-page press release, Kentucky never identified THC liquids as the probable cause of the lung injuries, and failed to inform marijuana users about the dangers of unregulated THC products. Officials urged the public “to stop using all vaping products,” which is likely to send those former smokers who had successfully switched to e-cigarettes back to smoking.   

The Kentucky Health Cabinet boasts that it “is one of the largest agencies in state government, with nearly 8,000 full- and part-time employees located across the Commonwealth focused on improving the lives and health of Kentuckians.”  It is regrettable that with all these resources, public health officials are distributing misleading information that may contribute to higher smoking rates.

Australian tobacco researchers, led by Coral Gartner at the University of Queensland, have published a scathing analysis of how THC-related lung injuries and deaths in the U.S. were – and still are – exploited by American health officials and media to fuel a crusade against e-cigarettes and nicotine vaping products.  The Australians itemize the key flaws in this misguided campaign:

“[M]ost [lung injury] cases developed suddenly within a short period, mostly in young males, in only one country. Over 40 million people have vaped nicotine in the UK, USA and Europe, and vaping has been around for nearly a decade without any similar clusters of serious acute cases of lung injury.  If vaping nicotine were the cause of these lung injuries, many more cases should have been reported in these countries…”

“[C]annabis oils, like nicotine‐based vaporisers, have also been used since around 2014 with almost no reports of lung injury. What recently changed is the proliferation of black market cannabis vaping products, some of which are sold in the same packaging as legal cannabis vaping products.”

“In October, the CDC concluded that vaping contaminated THC products was the likely cause of the lung damage.” 

While the CDC was slow to blame unregulated THC products, it is inexcusable that state health departments continue to release inaccurate information about dangerous products.

 

2019 NYTS Data Reveals Teen Vaping Up, Smoking Eradication Within Reach

The Centers for Disease Control and Prevention recently released data from the 2019 National Youth Tobacco Survey (NYTS).  My analysis confirms the FDA claim of an increase in vaping among high school students, as seen in the chart at left.  The most dramatic change is that exclusive use of cigarettes almost fell off the chart from 2018 to 2019, from 2.6% to 0.8%.  This unprecedented rate of decline suggests that the eradication of combustible cigarette use among high schoolers is within reach.

Government health officials are finding in the NYTS some added support for their claim of an e-cigarette epidemic.  Exclusive current (past-30-day) use of electronic cigarettes rose from 15.1% the year before to 22.4% in 2019.  The following table breaks down the numbers for both years, showing legal and underage vapers, those who currently/previously used other tobacco products or were virgin vapers; and how frequently virgin vapers used e-cigarettes.

Comparison of High School Vaping in 2018 and 2019
	2018		2019
U.S. High School Students	14.8 million		15.0 million
Current Vape	3.1 million		4.1 million
Legal (18+ yrs)	↓	600,000	↓	779,000
Underage	2.5 million		3.32 million
Used other tobacco	↓	1.7 million	↓	2.17 million
Vaping ”Virgins”	807,000		1.15 million
Vaped 1-19 days past month	↓	712,000	↓	978,000
Vaped 20-30 days	95,000 (0.6%)		171,500 (1.14%)

The 2019 numbers in all categories are higher than the year before.  Current vapers rose from 3.1 to 4.1 million, reflecting similar increases in both legal and underage groups.  Among the latter, virgin vapers grew at a higher rate (13%) than those who had used other products (9.4%). 

The number of frequent virgin vapers (using 20-30 days in the past month) increased from 95,000 to 172,000.  This means that 1.14% of underage American high school students with no other tobacco use might be addicted to vaping nicotine.  Although this is cause for concern, it is far from “a public health crisis in which a new generation is becoming hooked on nicotine,” as the New York Times put it (here).

High rates of marijuana use via vaping was a very important finding in the 2018 NYTS that was ignored by federal authorities, which borders on irresponsible when marijuana products were the cause of lung injuries and deaths.  However, it gets worse: marijuana wasn’t mentioned at all in the 2019 questionnaire, suggesting that CDC survey administrators were uninterested in making a distinction between cannabis and tobacco. 

In many previous posts about the NYTS, I have been reluctant to connect the sharp increase in teen e-cigarette use with the historic decline in cigarette smoking.  However, there is now no doubt that the two behaviors are directly related, a situation that will produce a significant public health benefit in the long run.  Even if a small fraction of these high schoolers end up addicted to vaping nicotine, the health risk will be a tiny fraction of the risks associated with smoking. 

While no one should be comfortable with underage teen drug use in any form, moral outrage about nicotine use is entirely misplaced.  Society accepts the widespread enjoyment of the addictive but largely benign drug caffeine – there is no Campaign for Caffeine Free Children screaming for coffee and cola flavor bans, excise taxes, Coffee 21 and burdensome federal regulation, for example. Nicotine should be tolerated in a similar fashion.

Moral outrage is best directed at alcohol and marijuana, addictive substances that are clearly associated with teen injuries and deaths.

Congratulations Minnesota! You “Saved” 32,400 Smokers from Quitting

Minnesota in 2010 became the first state to impose an e-cigarette excise tax, set at 35% of the wholesale price.  Three years later, the tax was increased to a whopping 95%.  It remains the nation’s highest e-cigarette tax.

Economists at the National Bureau of Economic Research, the City University of New York and Bentley University just released a report on the consequences of the Minnesota tax.  Henry Saffer and colleagues looked at U.S. Census Bureau surveys from 1992 to 2015, in order to understand Minnesota smoking trends compared with states that did not impose a large e-cigarette tax.  Saffer and colleagues excluded Massachusetts and Illinois, where cigarette excise taxes rose by $1.00 after 2010.

Figure 4 from the publication illustrates Saffer’s results.  While the decline in smoking flattened out in Minnesota after e-cigarette taxes were levied, the decline in the rest of the U.S. remained more pronounced. 

Saffer and colleagues report: “We find consistent and robust evidence that the e-cig tax in MN increased adult smoking relative to what it would have been in the absence of this tax… In 2014 there were about 600,000 adult smokers in Minnesota.  Our estimates indicate that the e-cig tax deterred about 32,400 adult smokers from quitting.” (emphasis added)

The authors add a warning to legislators and policymakers across the U.S.: “Currently there are approximately 34 million adult smokers.  If the Minnesota tax had been a national one, we estimate that it would have deterred around 1.83 million smokers from quitting.  Some have suggested that e-cigs should be taxed at the same rate as cigarettes.  Implementation of that policy would raise the price of e-cigs by approximately 62 percent, increase smoking participation by 8.1 percent, and deter approximately 2.75 million smokers from quitting.”

Saffer’s findings compliment those from a study earlier this year by economists at Georgia State, Temple University and the University of Kentucky.  Michael Pesko and colleagues found that “higher traditional cigarette taxes reduce adult traditional cigarette use and increase adult e-cigarette use, suggesting that the products are economic substitutes.” 

Two years ago, my colleague and I published a tobacco tax proposal for Kentucky.  We encouraged lawmakers to raise the cigarette tax but keep the tax on smoke-free products low (for smokeless) or nonexistent (for e-cigarettes).  Our proposal was adopted by the Kentucky legislature in 2018. 

Making e-cigarettes less accessible and more expensive keeps smokers smoking.  Unfortunately, this simple economic concept is routinely ignored by tobacco prohibitionists at all government levels.