Necessity is the mother of invention, and cigarette smokers are in dire need of invention.
Few stigmas are as pervasive today as the one surrounding tobacco use, but it serves a valuable purpose. “Cigarette smoking is responsible for more than 480,000 deaths per year in the United States,” the Centers for Disease Control warned in 2018. “Tobacco-related deaths account for about one in five deaths annually, or 1,300 deaths every day.”
Smoking has become burdensome for smokers, and not just when it comes to breathing. The turnaround began in the 1970s, at a time when 40 percent of the population smoked daily. It declined to 32 percent in the 1980s, and as taxes on its consumption as well as restrictions on its public use became increasingly onerous, fell to 21 percent by the turn of the 21st century. But in the mid-2000s, the rate of decline leveled off. Social stigmatization, financial burdens, and conventional nicotine-replacement therapies had achieved what they could. Then came the personal nicotine vaporizer.
“Vaping” isn’t a new technology. The first vaporizer patents were filed as long ago as the 1920s. But it wasn’t until 2003, when Chinese pharmacist and cigarette smoker Hon Lik invented a reliable method for dispersing nicotine in a cloud of mist, that “vape” technology became convenient and widely adopted.
Lik’s vaporizer applies a small, rechargeable heating element to a mixture of either propylene glycol or vegetable glycerin, as well as nicotine and flavored additives, to simulate not just the chemical satisfaction smokers derived from cigarettes but the sensation of inhaling smoke. It was a breakthrough nicotine- replacement therapy, and consumers immediately recognized its benefits.
One of the first major producers of a commercial nicotine vaporizer in the U.S., N’Joy, entered the market in 2007. And it wasn’t just consumers and entrepreneurs who saw the promise in vaping technology; so, too, did tobacco companies. All of N’Joy’s successors in the e-cigarette marketplace would be owned to some degree by the tobacco industry. By 2013, Vuse, an electronic cigarette manufactured by the tobacco company R.J. Reynolds, had overtaken N’Joy as the market leader, but its dominance was short-lived.
Juul entered the marketplace in 2015, and it quickly took off. There are still plenty of smaller producers of vaporizers on the market, as well as a variety of e-liquid manufacturers, all of which compete for space on the shelves of e-cigarette retail outlets small and large. But by 2017, Juul had become the undisputed industry leader, and, in 2018, it sold a minority stake to the tobacco giant Altria, the parent company of Philip Morris.
In the 2010s, smoking rates began to decline once again, and precipitously. Adult cigarette-smoking rates fell from 21 percent of the population in 2010 to just 15 percent in 2015. This diminution coincided with an increase in vaping, and some studies began to suggest a correlation. A UK-based study published in the New England Journal of Medicine found electronic cigarettes to be a more effective cessation product than traditional nicotine-replacement therapies. “The e-cig users were more likely to have not smoked traditional cigarettes, had less cough and phlegm production at the end of a year and had less severe urges to smoke than those on replacement patches and other forms of nicotine replacement,” read CNN’s summary of the study.
The correlation between the marked decline in smoking rates and the rise of vaping is unprovable. Still, that e-cigarettes can aid smoking-cessation efforts and present the prospect of significant harm reduction is not conjecture. A peer-reviewed study published in the British Medical Journal found that the widespread substitution of tobacco use with vaping over a 10-year period could lead to between 1.6 and 6.6 million fewer premature U.S. deaths. By contrast with smoking, vaping involves no combustion and produces fewer particulates and carcinogens and negligible carbon monoxide emissions. A 2018 National Academies of Sciences, Engineering, and Medicine study confirmed that, while the long-term effects of vaping weren’t clear, what was clear is that the “lower level of toxicants” in vaporized aerosols compared with tobacco smoke put consumers at “less risk.”
And yet, it was soon apparent that vaping’s appeal was not limited to adults or even smokers. Teenagers were also attracted to the product. Young people who had never used tobacco and may never have been interested in cigarettes were picking up a device that essentially taught them how to smoke, thus courting an avoidable nicotine addiction in the process. In 2017, just over 10 percent of high-school students reported using an e-cigarette at least once in the last month. By 2019, that number exploded to 28 percent of high-schoolers. Even though it is illegal to sell vaping products to minors, last year’s National Youth Tobacco Survey found that an estimated 5.3 million teens used e-cigarettes. And while many young e-cigarette users consume inhalants that contain no nicotine, studies suggest that those who do risk retarded brain development.
And yet, despite fears that this trend would lead to a corresponding increase in teen smoking, that outcome has not materialized. The same survey that found a radical increase in teen vaping also showed that just 6 percent of young people reported smoking a cigarette within the last month. Moreover, smoking rates among young people declined over the decade in which vaping became popular, from 15.8 percent in 2011 to just 5.8 percent in 2019. The Food and Drug Administration irrationally described these findings as “undermining progress toward reducing overall tobacco use.” That myopia is indicative of an extensive and conscious effort by policymakers to blur the distinctions between a combustible tobacco product like a cigarette and an electronic inhaler that contains no tobacco.
Almost from the moment vaping began to be widely adopted, anti-smoking interest groups and the politicians with which they are aligned waged a tireless campaign against the vaping industry. In 2009, California Governor Arnold Schwarzenegger vetoed a bill that would have banned e-cigarettes altogether. In 2010, the D.C. Circuit Court of Appeals found that an FDA effort to label e-cigarettes a “drug delivery device” and effectively ban them entirely was groundless because vape manufacturers did not make any therapeutic claims and were not misleading consumers about their efficacy as a smoking-cessation product. This was a decision the left-leaning online magazine Slate characterized as siding “with the tobacco industry,” even though the plaintiff, N’Joy, was not owned by any tobacco company. New York City Mayor Mike Bloomberg signed a law in 2013 prohibiting the use of electronic cigarettes anywhere that the use of tobacco is prohibited, despite the lack of evidence suggesting negative health outcomes resulting from secondhand exposure to vaporized e-liquids.
As part of this campaign, anti-smoking organizations flooded media outlets with background information on this new technology that elided the distinctions between it and conventional tobacco use. Advocates for e-cigarette bans, such as Harvard Medical School’s Jonathan Winickoff, likened vaping to “bioterrorism.” Citing “experts” and substance-abuse counselors, CNN asked whether the uptick in youth vaping represented “the health problem of the decade.” In 2013, a Centers for Disease Control study observed an increase in vaping among young people even as the use of tobacco products among high-school students had decreased. Matthew Myers, president of the Campaign for Tobacco-Free Kids, claimed the study found that “e-cigarettes could be a gateway to nicotine addiction and use of other tobacco products” when it seemed to suggest the opposite. Myers’s distortion was echoed uncritically in media outlets including NBC News, Time, and the Washington Post.
In 2016, Stanton Glantz, a professor of medicine at the University of California who is a prolific source of quotes in articles questioning the value of vaping, joined with his colleagues to publish a study purporting to show that smokers who use e-cigarettes as a nicotine-replacement device reduced their chances of quitting by 28 percent. The groundbreaking report was widely cited in the press but not heavily scrutinized. But as the Competitive Enterprise Institute’s Michelle Minton observed in her 2018 study entitled “Fear Profiteers,” when Glantz’s findings were examined, they were found to be “grossly misleading,” as one professor with London’s Queen Mary University put it. “I am concerned at the huge damage this publication may have,” wrote Ann McNeill, a tobacco-policy expert with the National Addiction Centre at King’s College, London. “Many more smokers may continue smoking and die if they take from this piece of work that all evidence suggests e-cigarettes do not help you quit smoking; that is not the case.”
As these assertions do not comport with the relevant (albeit preliminary) data, they can only be described as misinformation. And this campaign is having the desired effect on the public. In 2012, survey respondents to the national Tobacco Products and Risk Perception Surveys and the Health Information National Trends Surveys found that a plurality of adults believed that vaping was less harmful than smoking. By 2017, however, the number of adults responding to those surveys who said vaping was as or more harmful than traditional tobacco had tripled. The same numbers are reflected in media-sponsored polls, too. A 2019 Reuters/Ipsos survey found that a staggering 63 percent of adults disagreed with the idea that “vaping is healthier than traditional cigarettes”—a 16-point jump from a 2016 poll asking the same question. That same survey found that only 29 percent of adults thought vaping was an effective way to help smokers quit.
The news outlets that could not point to a direct link between vaping and tobacco use cited studies that predicted a link would surely materialize at some point in the future. “Hundreds of thousands of those young people will develop a nicotine addiction and ultimately switch to smoking regular cigarettes,” the Los Angeles Times reported last year. The article cited a study that used a Monte Carlo simulation—an odds game—to conclude that nearly a half-million e-cigarette users would eventually develop a tobacco addiction. Other outlets advanced the notion that e-cigarettes were dangerous because they were unpoliced. Business Insider claimed the electronic cigarette industry is “largely unregulated.” That would come as a surprise to the vaping industry since Congress granted the FDA the capacity to “deem” vaping instruments a tobacco product and regulate them accordingly as early as 2009.
By 2018, the public and lawmakers had been thoroughly primed to see vaping as an extension of the health crisis posed by tobacco use. That year, then–FDA Commissioner Scott Gottlieb pledged that his agency “wouldn’t allow the current trends in youth access” to vaping products “to continue, even if it means putting limits in place that reduce adult uptake of these products.”
Then people started dying.
_____________
Beginning in the late summer of 2019, a new sickness began to be observed among self-described vapers. Observers reported 450 cases of vape-related lung illness across 33 states by September; five of those who were sickened eventually died. Though vape-related emergency-room visits peaked that month, the number of reported illnesses continued to increase. In late December, the number of infirm had risen to over 2,500, with 54 deaths. Health experts were stunned, and some advocated the total prohibition of all e-cigarettes. “We need to pull these things off the shelves until we know what’s going on,” said Kansas State Health Officer Lee Norman. “If you or a loved one is vaping, please stop.”
The true cause of the crisis was not entirely unknown to medical researchers even in its earliest days. Though CDC researchers could not conclusively identify what was causing these illnesses, they did note that most who succumbed to lung dysfunction reported using vaporized marijuana products, some of which were purchased not from state-licensed distribution centers but off the streets. The overlap among users of vaporized nicotine and THC (the primary psychoactive compound in marijuana) products prevented researchers from being more specific about the precise source of the problem. Nevertheless, researchers identified the problem almost immediately: Rather than using propylene glycol or vegetable glycerin as the key emulsifying agent in vaporization, illicit THC products used vitamin E acetate—a synthetic form of vitamin E designed for use in topical skin creams.
As early as September 5, the FDA reported that most of the liquids it sampled from users who reported getting sick tested positive for vitamin E acetate. A New England Journal of Medicine study published the following day found that 84 percent of patients treated for vaping-related lung illness reported using THC products in e-cigarettes, not just nicotine products. The legal limbo in which THC products languish in states where marijuana is not explicitly illegal has contributed to this crisis. Unlike vape shops and e-liquid manufacturers, over which the FDA maintains extensive oversight, THC products in these states are not well monitored. Cannabis producers have been accused of lacing their products with pesticides, fungicides, and growth hormones to produce high yields as quickly as possible. The use of more readily accessible emulsifying agents such as vitamin E acetate is just another cut corner, but one that evidence suggests was responsible for large-scale pulmonary injury.
Even former FDA Commissioner Gottlieb, no fan of vaping himself, confessed that the likely culprit behind the uptick in lung injuries was illicit marijuana products. “It’s probably something new that has been introduced into the market by an illegal manufacturer,” he told the New York Times, “either a new flavor or a new way to emulsify THC that is causing these injuries.” But even though Gottlieb’s conclusion was derived from publicly available information, neither media nor policymakers were especially interested in it. They had been conditioned for nearly a decade to believe that nicotine vape products were as suspect as cigarettes, and they wasted no time implementing an agenda they’d long sought.
Within weeks of the uptick in vape-related illnesses, states including New York, Michigan, Utah, Montana, Washington, Oregon, as well as the city of Los Angeles announced bans, not on all vaporized inhalants, but only on the flavored e-cigarette liquids that anti-smoking advocates had for years insisted were marketed to children. The FDA announced its intention to pursue the ban of flavored e-liquids it had telegraphed for months, and that prohibition took effect on January 2, 2020. The evidence to suggest that the skyrocketing rates of e-cigarette use among young people had contributed to increased tobacco use was scant, but this agenda had a life of its own now.
See if you can follow this logic. Kids might be enticed by flavored e-cigarettes to use tobacco products. Therefore, we must ban e-liquids that are not flavored like cigarettes to make sure that kids will learn to associate nicotine with tobacco. Even if you can discern some merit in this ponderous rationale, it surely doesn’t have anything to do with the spate of deadly pulmonary afflictions resulting from the use of illicit THC products. Nevertheless, enemies of the vaping industry likely thought that they were dealing a deserved blow to Big Tobacco, which they believe has used aerosol nicotine products to get a new generation hooked on the addictive chemical.
They might be surprised to learn that some of the first advocates to call for e-liquid flavor bans were tobacco manufacturers themselves.
“We believe the FDA should not allow such products to be sold or marketed,” said Reynolds American Inc. (manufacturer of the e-cigarette Vuse) spokesman David Howard in 2014. He noted that many e-liquid manufacturers operate overseas, produce open systems that are easily tampered with and adulterated, and create “flavors that may be appealing to youth,” a practice from which cigarette makers are legally barred. Indeed, some legacy tobacco manufacturers were among the earliest advocates of the legislative effort to retroactively “deem” e-cigarettes subject to tobacco’s regulations.
The firms that supported that effort ostensibly did so in response to consumer health and safety concerns, but when vape products were subjected to FDA oversight, tobacco companies controlled less than 40 percent of the market for vape products. The rest of the marketplace was made up of foreign firms and smaller, independent manufacturers. The regulatory environment Big Tobacco championed helped push smaller producers out of the marketplace. Today, most of the major producers of e-cigarettes in the United States were either created or are partly owned by Big Tobacco companies.
If anti-vaping policies have been good for tobacco producers, they’ve also been good for major pharmaceutical manufacturers. Nearly $100 billion was invested in the development of such conventional nicotine-reduction treatments as patches, gums, and lozenges, and they constitute a $6 billion-per-year business. As CEI’s Minton demonstrated in meticulous detail, the financial and organizational links between the anti-smoking advocacy community, the pharmaceutical industry, trial lawyers, and the public sector were key to the effort of making vaping as difficult as possible. There’s no small amount of irony in the fact that they can count on the tacit support of Big Tobacco, which also benefits from the artificial hurdles that force their competitors in the e-cigarette industry out of business.
Though some tobacco producers opposed the 2009 law that allowed the FDA to regulate vaping as it did traditional tobacco products, others, such as Altria, publicly supported the effort. Ahead of the passage of that law, Bill Goodall, the founder of Smoke-Free Pennsylvania, told the New York Observer that Altria “secretly negotiated” with anti-smoking advocacy groups such as the Campaign for Tobacco-Free Kids and lobbyists for pharmaceutical nicotine-reduction treatment manufacturers such as GlaxoSmithKline, the maker of the popular replacement therapies NicoDerm and Nicorette. Altria appeared to confirm the allegation, confessing that “there were a variety of stakeholders from public health, tobacco control, and manufacturers who gave input.” Indeed, Altria was candid about its motives. With cigarette sales decreasing in volume by about 3 percent per year, the firm aimed, in the words of spokesman Brian May, to be “a leader in the vaping space.”
Anti-tobacco groups such as Truth Initiative and Campaign for Tobacco-Free Kids, which are funded in part via grants from groups like the Robert Wood Johnson Foundation—the philanthropic organization that remains the largest shareholder of Johnson & Johnson stock, which owns the rights to market popular nicotine-reduction treatments like Nicorette outside the U.S.—disseminate dubious talking points to media outlets and government entities, and that language finds its way into the mouths of politicians and regulators. Their anti-vaping advocacy is presented to the public as virtuous anti-smoking efforts when the tobacco companies don’t seem to mind the new legal impediments imposed on their smaller competitors. Thus, a self-reinforcing closed loop of vested interests and well-intentioned policymakers conspired—wittingly or otherwise—to restrict access to a smoking-cessation aid. Their combined efforts have dealt a severe blow to one of the more effective harm-reducing tobacco alternatives on the market.
We want to hear your thoughts about this article. Click here to send a letter to the editor.
