Advanced Research Efforts Required in Response to Vaping Epidemic

In 2019, the U.S. was plagued by an outbreak of vaping-related illnesses responsible for the deaths and lung conditions of young users in particular. As of mid-Dec., the CDC had confirmed 52 deaths in 26 states including the District of Colombia and 2,409 hospitalized cases across all 50 states and two U.S. territories. Researchers at the University of Wisconsin-Milwaukee have concentrated their investigations in response to the recent outbreaks.

The first reported cases of e-cigarette, or vaping, product use associated lung injury (EVALI) were identified in April 2019 in the Midwest—specifically Illinois and Wisconsin where marijuana use has not yet been fully legalized.

With more than 460 e-cigarette and 152 THC-containing product brands, the CDC has issued warnings for users to understand the health risks accompanying vaping trends that have been growing in popularity, especially among young adults.

“The greatest challenge is that the initial message from health departments and the CDC was that everyone should stop vaping everything,” said Linnea Laestadius, an associate professor of public health policy and administration at UWM’s Zilber School of Public Health. “The problem with that is that if you are a THC vaper, you don’t usually consider yourself an e-cigarette user or a vaper—you consider yourself a cannabis user. The concern is that the initial messaging is missing the users who are at the highest risk.”

After receiving a doctorate in public health policy at Johns Hopkins Bloomberg School of Public Health, Laestadius’s research and teaching interests focus on public health advocacy, communications and policymaking. She analyzes how social media content influences behavior and the ethics of novel technologies in regard to privacy and equity.

Funded by the Food and Drug Administration and National Cancer Institute, Laestadius’s research has been rooted in online and social media context regarding e-liquid marketing and how it shapes public health behaviors. Her students are analyzing news coverage and communications in terms of risks and precautionary messaging.

The first electric vaporizer was designed in 1927 by Joseph Robinson as a “safe” alternative to cigarettes, according to Insider. In 2003, the first commonly recognized e-cigarette was produced in China and was later introduced to Europe and North America in 2006.

The ingredients in e-liquids typically contain a varying amount of chemicals, alcohols and additives including vitamin E acetate, which has been attributed to recent EVALI cases, according to the National Center for Biotechnology Information.

As a user inhales, the coils in the vaping mechanism heat up and turn the e-liquid to an aerosol, which is then breathed into the lungs. Traces of toxic metals like cobalt can then leach into the e-liquid and cause permanent damage.

“There are a lot of things we don’t know yet that need to be figured out,” Laestadius said. “No one in the U.S. has really been focusing on making vaping safer because everyone is so busy worrying about the fact that people are vaping in the first place.”

Other potential hazards linked to black market THC products and nicotine vapes include increased susceptibility to lung illnesses like pneumonia and instances of vaping mechanisms exploding during use.

The different vaping devices under investigation include e-cigarettes, vape pens, JUUL, THC cartridges, vape mods, electronic hookah among others. Some brands of THC-containing products like Dank Vapes are notoriously counterfeit and one of the most widely used unregulated products that contain traces of vitamin E acetate.

“Most people know what kind of thing they’re buying, which is useful in letting people identify risky materials,” Laestadius said. “Kids will just take a ‘hit’ off of anything, which is a whole separate and very large problem.”

The 2019 National Youth Tobacco Survey found that about one-third of high school students were current tobacco product users while another study by the British Medical Journal found that one-tenth of high school students had vaped cannabis. Youth who reported e-cigarette use were found to be nearly four times more likely to smoke, according to the Journal of the American Medical Association.

A student nurse in UWM’s College of Nursing Maighread McAvoy said that common incentives for young users include trendsetting and social status attained through usage.

“They don’t see the danger behind it,” McAvoy said. “It’s idolized in popular culture and trends like ‘YOLO’ and ‘Vape Nation’. They don’t think as much as other age groups about the long-term implications.”

McAvoy said that in the case of the 17-year-old Michigan boy who received the first vaping-related double-lung transplant, individual cases aren’t enough to get young people to reverse the mentality that they won’t be next.

Some institutions have tried to implement smoke-free zones, but McAvoy believes that “when you make those regulations, you ostracize that group and lose that understanding you need in order to help them.”

Massachusetts implemented a temporary vaping ban as a precautionary measure that allowed the state time to investigate the cases while countries like the United Kingdom have taken different regulatory approaches. England’s National Health Service has emphasized a harm reduction directive by banning additives and offering alternative health resources.

Laestadius suspects that because the U.S. has not been taking this approach, vaping has inadvertently become more interesting to younger demographics because of its foreboding propensity.

For other users who have turned to vape as an alternative to smoking, “there are a lot of grey areas,” according to Laestadius. “We want vaping to exist as an exit ramp from smoking, but we need to find some way to regulate e-liquids so that they are safe and useful to adults without appealing to kids.”

Laestadius has worked with tobacco control groups in the area including the City of Milwaukee Tobacco-Free Alliance and others who are targeting specific minority populations.

When a smoker is unsuccessful in trying FDA approved tools for quitting, a safer alternative for cigarettes would be vaping if they’re not able to quit altogether, according to Laestadius. “It’s dependent on who you are, why you’re vaping and what you might be doing to stop smoking.”

In 2016, the FDA effectuated the regulation of all tobacco and vaping products. However, regulations are still subject to change as continued research efforts are underway to understand the causes and consequences of EVALI cases.

The CDC has not yet determined the full range of compounds or ingredients responsible for vaping-related illnesses nor the commonalities between e-cigarette or vaping product usage.

Laestadius suggests that while vaping will never be completely safe, it would make sense to shift the focus to how vaping can be made safer by regulating what goes into e-liquids.

“If I had to create a public message, it would be that if you are vaping THC, particularly if you obtained that THC illegally, you should not be vaping that,” Laestadius said. “The risk is too high—we don’t know what’s in that THC liquid at this point.”