Tag Archive nicotine

The Truth About the Vaping Crisis (Ep. 398)

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After more than 40 demises, some states and metropolis have censored vaping produces, many of which are used as smoking-cessation manoeuvres. Meanwhile, roughly 500,000 people die each year from inhaling, and cigarettes are still widely available.( Photo: Burton/ Getty)

A recent eruption of illness and death has get everyone’s attention — including late-to-the-game regulators. But would a ban on e-cigarettes do more harm than good? We smoke out the facts.

Listen and are contributing to our podcast at Apple Podcasts, Stitcher, or elsewhere. Below is a transcript of the episode, edited for readability. For more information on the people and ideas in the chapter, encounter the links at the bottom of this post.


Unless you’ve been hibernating, you’ve probably been hearing about the dangers posed by e-cigarettes and vaping.

CBS News: Two more beings have died from vaping-related illness, this time in Minnesota. This generates the national toll to 31 deaths across 22 states.

Good Morning America: Public health officials report there are nearly 1,300 probable or confirmed injuries applicable to vaping in 49 nations.

These specimen involve a severe respiratory ailment that’s been labeled EVALI, or “e-cigarette, or vaping, product-use-associated lung injury.” Doctors in Detroit recently accomplished double lung-transplant surgery on one EVALI victim. Even though beings have been vaping for years, the deaths are new, and the information has been met with something between alarm and panic.

PBS NewsHour: The Federal Government today counselled Americans not to use e-cigarettes following various strange deaths having links to vaping.

The caution is understandable. More than 40 million people around the world now vape, up from really 7 million less than a decade ago. In the U.S ., roughly 1 in 5 high-school kids vape.

Vivek MURTHY: I think that when it is necessary to specially the health of our children, we cannot afford to take risks.

That is former U.S. Surgeon General Vivek Murthy.

MURTHY: And once millions of children are using e-cigarettes who should have never been exposed to these devices.

But while the U.S. is trying to beat back the ebb of vaping, there’s different countries that’s been encouraging it.

Michael SIEGEL: In the U.K ., they’ve actually espoused electronic cigarettes as a damage reduction programme.

But what about EVALI and the risk of death?

SIEGEL: I don’t know of any cases of respiratory failure that have been reported in the U.K.

How can that be? Today on Freakonomics Radio, a falsehood of two public-health strategies. One that leans towards abstinence 😛 TAGEND

MURTHY: We don’t have the comfort, I repute right now, of trying to parse which flavors might be okay, which may not be okay.

The other, trauma reduction 😛 TAGEND

Dorothy HATSUKAMI: It certainly thumps 7,000 chemicals that you get from cigarettes.

What’s known — and not known — about vaping.


Before there were e-cigarettes, there were cigarettes. Merely how favourite were cigarettes? In the 1950 s, 45 percent of adult Americans indicates that they smoked — and that’s a self-reported number, so the actual amount may have been even higher. Back then, cigarette ads were still stood on TV.

Vintage Camel Cigarette Jingle: How mild, how mild, how mild can a cigarette be? Make the Camel 30 -day test, and you’ll watch.

Cigarettes had some influential endorsers.

Vintage Camel Cigarette Advertisement: Harmonizing to this reiterated national questionnaire, more doctors inhale Camels than any other cigarette.

They shaped smoking music fairly darned good.

Vintage Chesterfield Cigarette Advertisement: Medical doctors reports no adverse impact for the nose, throat, or sinuses from inhaling Chesterfields. Now, don’t you want to try a cigarette with a record like this?

But eventually, a ridge of scientific sign developed — much of which had been suppressed by cigarette companies — showing that cigarette smoking greatly increases the risk for a number of cancers as well as myocardial infarction, movement, and other bad outcomes. In many countries, smoking is still incredibly common. According to the World Health Organization, 76 percentage of adult servicemen in Indonesia still smoke cigarettes; in Russia, it’s 59 percentage; in China, 47 percent. But in non-eu countries, the smoking charge has precipitated steeply and continues to fall. In the U.S. and the U.K ., for instance, only about 20 percentage of adult males now smoke. This wane is considered one of the greatest public-health success of all time. How did it happen?

Jonathan GRUBER: So, certainly, the sort of firstly disturbance to the system was the spread of information that smoking is bad for you, which started a big drop in smoking, but predominantly among the well-educated.

That’s Jonathan Gruber, a health care economist at M.I.T.

GRUBER: If you look at smoking frequencies by education radical, it fell precipitously for the most improved and much more slowly for the least educated.

Beyond the information channel, there are still regulations that led to much higher premiums and taxes. And that, Gruber says, specially helped drive down smoking among younger people.

GRUBER: We have lots of evidence that youths are extra-sensitive to price, which kind of becomes appreciation, right? Youths don’t have a lot of fund.

In the late 1990 ’s, more than 35 percent of American high-schoolers smoked; today, that figure is less than 10 percent. That said, cigarette smoking in the U.S ., as in many other countries, remains the leading cause of preventable death. The Centers for Disease Control attributes 1 of five American fatalities to smoking. That’s nearly half a million deaths per year, or 1,300 beings a daytime. If you add up all the people who die from booze and illegal drugs and automobile accidents and suicide and slaying — those are still outnumbered by smoking fatalities. How can this be? How can something so demonstrably dangerous be freely consumed by so many parties? In a word, nicotine, the stimulant may be in the foliage of the tobacco plant.

HATSUKAMI: What nicotine does is, it targets neural receptors in the mentality.

That’s Dorothy Hatsukami, a psychiatry prof at the University of Minnesota. She’s a prominent expression in cancer avoidance and a member of several national scientific-advisory boards dealing with tobacco use and other drug abuse.

HATSUKAMI: Targeting those neural receptors leads to the release of a number of compounds in the mentality, and these compounds feign mood as well as cognition. And the committee is also actually makes people want to seek more nicotine.

In other words, nicotine is most addictive. The lust for nicotine has helped condition civilization. The tobacco plant, thought to be native to the Americas, has been smoked or ruminated for at least 2,000 years, often held to religious or cultural ceremonies. European explorers to America brought tobacco back home in the 16 th century, and its use spread speedily. This require have all contributed to big tobacco plantations back in America, which in turn fed the demand for slave labor. Much of the early American economy was organized around tobacco; it was even used as currency. But here’s the thing: nicotine, tobacco’s most valuable component, the ingredient that represents it so hard to quit smoking — nicotine is not the biggest villain of this story.

HATSUKAMI: What is problematic is that nicotine is delivered in a really dirty delivery system, and that’s the cigarette, which contains a number of toxicants.

Among the toxicants that get into your lungs when you smoke a cigarette are benzene, ammonia, arsenic , and lead. And what about the nicotine itself?

HATSUKAMI: Nicotine is not harmless, by any means. Nicotine effects addiction. It has negative effects on a fetus. It might increase the risk factors for cardiovascular disease, and also it apparently does feign the developing brain. But it’s certainly not the most harmful constituent in a tobacco commodity.

Nicotine also has some established benefits.

HATSUKAMI: Yeah, certainly nicotine “ve been able to” some beneficial effects on cognition. And it can help sustain attention, for example.

It may disappear even beyond that. Paul Newhouse, a psychiatry professor at Vanderbilt, told us a few years ago that nicotine rehabilitation may prove useful for a number of ailments.

Paul NEWHOUSE in a previous Freakonomics Radio bout: Things like memory-loss diseases, Alzheimer’s disease. We’ve looked at ADHD. Other inspectors have looked at everything from Tourette’s Syndrome to feeling disorders to recession. I think that the full potential of nicotine and nicotinic dopes is genuinely not even perfectly is known.

Others are not so hopeful.

Robert WEST: I consider the potential benefits of nicotine are at best controversial, to be honest.

Robert West is a professor of health psychology at University College London and journalist of the periodical Addiction.

WEST: There was a lot of research back in the 80′ s and 70′ s around the idea that nicotine might help with concentration and be a cognitive enhancer. But that kind of research didn’t really bear fruit. Whether it’s helpful in other conditions — I intend some people have suggested Parkinson’s — I think is moot, to be quite honest. Even if it were beneficial, I disbelieve much needed whether it would be as effective as the other treatments we already have.

HATSUKAMI: Well, there probably isn’t as much known about that area as we would like.

What is known about nicotine is this: it is so advisable, so addictive, that millions upon millions of people are willing to inhale cigarette smoke — including the lead, arsenic, ammonia, and benzene — in order to get the nicotine. Not that they undoubtedly want to: approximately 70 percent of U.S. adult smokers say they want to quit smoking.

HATSUKAMI: So one of the goals, then, is to actually try to reduce the addiction to these highly toxic concoctions and genuinely change smokers over to less-harmful products.

Less-harmful nicotine commodities have been around for years: gum and patches and nasal sprayings. How effective are they? Not extremely. One analysis pointed out that exactly 14 percent of smokers are able to quit when they use one programme of nicotine-replacement therapy. The figure increases to 17 percentage when using, say, a nicotine spot and gum at the same time.

HATSUKAMI: So one of the problems with the smoking-cessation pharmacological implements is that they are unappealing. They don’t have some of the sensory outcomes that people like when they’re smoking their cigarettes.

How about a inoculation against nicotine addiction? That is something Hatsukami worked on for years. In the early, proof-of-concept study, the results were promising. But ultimately came a large clinical trial.

HATSUKAMI: The results from this chapter 3 clinical trial, they were not positive. So that was unfortunate, but that’s not went on to say that the nicotine vaccine is a bad idea. I think it simply needs to be developed further.

So for years, that’s where things stood. Millions and millions of smokers, most of whom didn’t want to smoke but couldn’t stop. Nicotine-replacement cares that weren’t very effective. A inoculation that wasn’t ready. And then, in 2007, a brand-new make came to market. They’ve since come to be called Demise: electronic nicotine delivery systems — more commonly known e-cigarettes.

SIEGEL: When e-cigarettes first came on the market, my first assumption was that this is just another tobacco-industry ploy that they can say is safer but really isn’t and time goes more people to use tobacco.

That’s Michael Siegel, a physician and prof at the Boston University School of Public Health. He’s been researching tobacco topics for more than 30 years.

SIEGEL: After studying the issue, it became clear to me that this was very different. And the tobacco companionships actually weren’t involved at all. They didn’t get into the picture until 2011. And in fact, this was a much safer concoction and was helping numerous beings to quit smoking.

The earliest e-cigarettes didn’t have good battery life or deliver their nicotine efficiently. But the technology evolved, with the thousands of firebrands put forward by a variety of vaping maneuvers — some of which could be used for vaping other, more humorous substances. Here’s how the National Institute on Drug Abuse summarizes the category: “Electronic cigarettes are battery-operated machines that beings use to inhale an aerosol, which are usually contains nicotine( although not always ), flavours, and other chemicals. They can resemble traditional tobacco cigarettes, cigars, or hoses, or even daily entries like writes or USB memory sticks.” E-cigarettes proved fantastically favourite, for a number of reasons.

SIEGEL: There’s physical stimulant. There’s holding a cigarette. There’s feeling the throat smack, construing the cigarette comes out. There’s social stimulu — smoking with other parties in social settings.

A new word entered the global vocabulary — “vaping, ” or assimilating the vaporized content of these devices.

SIEGEL: I recall more than anything, what vaping offers to smokers is an identity. You don’t have an name as a nicotine-patch-user. Nicotine-patch-users don’t get together in groups and have forums and gatherings for the weekend, but vapers do.

It wasn’t long before a vaping champ was crowned: Juul Labs, founded in 2015 and headquartered in San Francisco. The Juul e-cigarette was elegant and minimalist and it came in flavors including mango, cucumber, and mint. By 2017, Juul was the U.S. supervisor in market share, selling one of every 3 e-cigarettes. Following the adjournment of 2018, the company was valued at $ 38 billion, and it sold off a 35 percentage stake to Altria, the tobacco being previously known as Phillip Morris. Why did Juul become so much more popular than its rivals? Michael Siegel has one answer.

SIEGEL: Juul has a very different nicotine formulation that offsets it something much addictive. It’s a nicotine salt. It’s sucked much more rapidly into the bloodstream. And because of that, it simulates the specific characteristics that you get with a real cigarette. And that is what represents Juuling so addictive.

And how does Juuling, or vaping any nicotine-based e-cigarette, compare to combustible cigarettes when it comes to toxicity? Dorothy Hatsukami again.

HATSUKAMI: Delivering nicotine via the electronic cigarette is far less toxic than the cigarette, but you still have constituents delivered — foreign ingredients delivered to the lung.

SIEGEL: In the testing that’s been done on e-cigarette aerosol, in many cases, they find no detectable different levels of any unwanted compounds. In other specimen, there are some substances, but only a few cases. And that doesn’t mean that the products are safe. Those substances could induce problems if applied over the long term. But the toxicological profile of these products indicates that they’re much safer than cigarettes.

HATSUKAMI: It’s not going to be a harmless concoction, but it certainly beats 7,000 chemicals that you get from cigarettes.

SIEGEL: The strongest evidence that demonstrates how these products are safer are clinical studies that have been done where smokers have switched to e-cigarettes and there’s been a drastic improvement in their respiratory run, both subjectively through their reported symptoms and objectively through spirometry testing, which has shown improvement in lung part among these now ex-smokers.

And what about the long-term effects of vaping, versus smoking cigarettes? What’s the data there?

SIEGEL: There’s no long-term data, because the products have not been on the market long enough to be able to do death studies to show that using e-cigarettes as opposed to cigarettes is going to lower mortality. The detail that we don’t have long-term studies doesn’t mean that it’s not going to save lives. We know it’s going to save lives based on the short-term clinical data that we do have.

So based on the current evidence: e-cigarettes sound like a considerable improvement over cigarettes, at least on some key features. This is the sort of tradeoff known in public-health curves as “harm reduction.” When parties engage in risky behavior, there are at least two ways to help. One is to simply point out how risky their behaviour is, and encourage them to stop. This is the abstinence approach. Abstinence may gaze good on paper, and it may seem perfectly logical to a public-health official or a programme producer who’s never been tempted by any risky behavior themselves. But when it comes to something like cigarette smoking and nicotine addiction — as the data have shown — abstention is a tough sell.

Harm reduction takes a different approach. This entails recognizing that some people are going to engage in risky behavior, and it’ll be a cyberspace better if you can come up with a less-risky version of that behavior. That’s the idea behind needle exchanges for heroin admirers and free condoms for boys. Or putting seat belts in autoes rather than restricting gondolas on the grounds that they’re too dangerous. Or getting cigarette smokers to use e-cigarettes instead. To a cancer researcher like Dorothy Hatsukami, this notion did not come easily. What was her original objective?

HATSUKAMI: Well, first, it was elimination of the use of tobacco concoctions wholly. But because so many people are addicted to the product, then my focus became, well, let’s take a look at harm reduction. If people can’t retire, then let’s “ve been thinking about” commodities that would reduce harm.

If someone like Dorothy Hatsukami could embrace, nonetheless reluctantly, e-cigarettes as suffering reduction, you’d think it would be a slam dunk for U.S. policy makers. But it wasn’t. In fact, e-cigarettes are currently not allowed to be marketed or promoted as smoking-cessation tools, the behavior nicotine gum or spots are. Why not? Okay, this is a little complicated but it leads like this: The Food and Drug Administration was only granted jurisdiction over tobacco makes, believe it or not, in 2009. E-cigarettes were still relatively new.

Rather than categorize them as tobacco commodities, the FDA categorized them as drug-delivery designs — which have much stronger limiteds than cigarettes — and the agency subsequently showed them illegal. The outcome was that their auction was, essentially, banned. The e-cigarette fellowships could have prosecuted sanction as a drug-delivery device. Instead, they sued, and triumphed, which led to the loss the FDA to reclassify e-cigarettes as tobacco products. This hoisted the ban on their marketing, but it also made they couldn’t be promoted as smoking-cessation manoeuvres since, according to the FDA, an e-cigarette mostly is a cigarette.

Now, this isn’t to say that plenty of smokers didn’t take up vaping; they did. A recent analysis in the Annals of Internal Medicine found that 54 percent of e-cigarette users too inhale regular cigarettes, but that 30 percent of vapers had quit smoking. At least for the time being. But if you are an e-cigarette company and you can’t market your concoction as a safer alternative to existing smokers, who might you market to instead? Specially if your make comes in spices like mint and mango and cucumber?

SIEGEL: Juuling has become quite popular among youth.

That’s right. While adult smokers trying to quit certainly drove the proliferation of the vaping manufacture, another demographic was coming secured at the same time. Vaping usage in the U.S. today is highest among people aged 18 to 24. Again, bear in mind e-cigarettes only came into existence 12 year ago. Roughly 20 percent of high-schoolers now vape regularly — more than double the share that smoke cigarettes. Which means that a lot of them didn’t smoke before e-cigarettes came along.

SIEGEL: There’s no question that a culture of smoking is being replaced by a culture of vaping. There is a very strong negative correlation between the prevalence of cigarette smoking among young persons and the prevalence of vaping among boy. And I think that it’s really the boy addiction to nicotine that’s their own problems. It’s not vaping itself. It’s the fact that kids are addicted. If you exactly vape for a couple of years as a high school student or a college student, there’s really not going to be any major adverse health effects. But if you become addicted to vaping and then you be brought to an end vaping for many, many years, there could be long-term health effects.

And the vape of alternative among young Americans is Juul. Was this intentional on Juul’s behalf? If you go to Juul’s website today, you’ll learn its mission is to “improve the lives of the world’s one billion adult smokers by eliminating cigarettes.” Note the words “adult” and “smokers” — that is, people who already inhale cigarettes. So how did Juul become so popular among adolescents who hadn’t previously smoked?

A study from the Stanford School of Medicine analyzed Juul’s early commerce activity, including many tweets that the company had since deleted. The researchers found that, mention, “Juul’s advertising imagery in its first six months on the market was patently youth-oriented. For the next two-and-a-half times it was more muted, but the company’s advertising was widely distributed on social media canals frequented by kid, was amplified by hashtag extensions, and catalyzed by reimbursed influencers and affiliates.” So, I’m no marketing expert but that is pretty purposeful. In all such cases, the sale of Juul’s sweet and fruity vaping machines skyrocketed among young people and drove the company’s valuation into the billions. It would also originate Juul the target of angry mothers, late-to-the-game regulators, and everyone trying to figure out why dozens of people were unexpectedly dying from vaping.


In the U.S ., there are two different people of people who use e-cigarettes: older adults, many of whom are trying to give up cigarettes; and young adults and adolescents, many of whom never smoked. Older adults vaping in order to quit smoking could be considered a public-health victory. Younger beings taking up vaping is considered a public-health disaster.

MURTHY: There really is no evidence that supports what was a widely shared thought a couple of years ago, that if these kids are using e-cigarettes, then that’s actually going to prevent them from consuming regular cigarettes.

That, again, is Vivek Murthy, who provided as U.S. Surgeon General under President Obama.

MURTHY: That was an argument that was widely made by the proponents of e-cigarettes several years ago.

But Murthy says there isn’t sufficient evidence for that debate. In other names, even if vaping is less injurious than smoking, vaping might eventually lead to smoking cigarettes.

MURTHY: The other issue is that even though e-cigarettes are nearly always going to be less destructive than traditional cigarettes — because again, they’re not combusted, and they don’t have the full display of harmful toxins — that doesn’t mean that they’re harmles. There are other chemicals in them. And because these were being produced and sold with so little oversight and regulation, we actually didn’t know, and still don’t know, in many cases, “whats in” these products.

DUBNER: Why has there been so little oversight and regulation?

MURTHY: I don’t a hundred percentage know why, but I do think it’s been route too slow. I do think that we have not done the job we need to do as a federal government. And once millions of children are using e-cigarettes who should have never been exposed to these devices.

DUBNER: So the British government took pretty much exactly the opposite approach of the U.S. Federal government departments. And they mostly looked at it years ago and said e-cigarettes are probably not the greatest thing in the world for people, but we believe that as a substitute for smoking, they could save a lot of lives. And the British government and their cancer and anti-smoking institutions offer evidence to argue that they have been correct.

MURTHY: Yeah. So the U.K. did take a different approach in some ways. They were more optimistic on the prospect of e-cigarettes being helpful for cease. But the U.K. was also very concerned about protecting children. And they actually made more regulatory measures — including restrain the amount of nicotine in e-cigarette products — which are things that we did not do here in the United Country. They tried to go at the problem more with a scalpel as opposed to with a blunt instrument. And I believe we struggled with that here in the United Commonwealth.

SIEGEL: Yeah, the U.K. has a very different approach to electronic cigarettes than we do in the U.S.

That, again, is Michael Siegel, the Boston University tobacco researcher.

SIEGEL: And that is that the U.K. has adjusted these products. And more importantly, there is a limit on the amount of nicotine that’s allowable. You are simply have up to 20 milligrams per milliliter of nicotine in your e-liquids. In the U.S ., there’s no restriction at all. So Juul comes along, they articulated 54 milligrams per milliliter in their make, and it’s no surprise that kids are get addicted. People may not realize this, but there is Juul in the U.K ., but they don’t have a youth Juuling problem. And the reason for that is you don’t have Juul at 54 milligrams per milliliter, you have Juul at 17. In this country, these commodities have not been cuddled for trauma reduction, but they’ve actually espoused electronic cigarettes as a mischief reduction policy. And as a result, the health care expenditure in the U.K. are going down.

Why have both countries approached the issue so differently? Here’s how Michael Siegel interprets it. In the U.S ., he says 😛 TAGEND

SIEGEL: There’s a huge stigma attached to smoking, and people who smoke have much less political strength, so it’s very easy to dismiss their concerns. In the U.K ., I don’t think that demonization has existed. There’s a lot less of this kind of prohibitionist or puritanical examine of wickedness that we have here. There’s a lot more expressing its concern about smokers and trying to find ways to get them to improve their health and save their lives.

And, as a result 😛 TAGEND

SIEGEL: The U.K. has not had as much of a problem with teenager vaping as we have. There are youth who vape, but the rates are not nearly as high and they don’t have a lot of youth who are addicted.

When Siegel says the British youth vaping rates are “not nearly as high” — well, he is not exaggerating: are in accordance with Public Health England, fewer than two percent of Britons under senility 18 application e-cigarettes at least weekly, the vast majority of whom smoke cigarettes as well. Among young people who don’t smoke, vaping is almost nonexistent.

SIEGEL: So I think that the lesson we need to learn is that you don’t superseded when you have a popular product by banning it. What works is regulating the product. And I belief had the FDA been regulating e-cigarettes from the beginning, had they position safety standards, including peak nicotine tiers, we would never have gotten into this mess. Juul could never have appeared because it wouldn’t have been allowed to come on the market with that high-end nicotine level.

So Michael Siegel’s proof is pretty interesting: public-health officials in the U.K. developed a regulatory plan for e-cigarettes that was meant to maximize smoking cessation among adults while restraint boy uptake. In the U.S ., meanwhile, an early try at a proscription have all contributed to a gloomy regulations and rules that didn’t further either those goals. It likewise left a company like Juul free to make and market a make that many beings now concur is too potent and extremely popular with too many young people. But the lack of regulation around vaping did more than simply that. It also paved the space for a public-health tragedy that seemed to come out of nowhere.

CBS News: A fourth demise has been reported from a severe lung illness linked to vaping.

CBS News: This draws the national fee to 31 fatalities across 22 states.

Actually, as of this record, the fatality total is 42, with more than 2,000 gashes, across nearly every state, all attributed to EVALI — “e-cigarette, or vaping, product-use-associated lung injury.” The problem involves chest pain, shortness of breath, and vomiting; and it’s been overwhelmingly centralized among young people — nearly 8 in 10 were under 35.

CBS News: Health officials believe some chemicals found in e-cigarette and dopes vaping products be held accountable, but they’ve not marked any single manoeuvre, concoction, or element that’s responsible.

And because no single device or make was identified, all vaping commodities were lumped in together as is practicable culprits — all the different designings and inventions and flavors, including the e-cigarettes thought to be the safest. You couldn’t accused parties for panicking.

PBS NewsHour: The Federal Government today told Americans not to use e-cigarettes following several inscrutable extinctions linked to vaping.

Michael Siegel again 😛 TAGEND

SIEGEL: The state of Massachusetts ratified an emergency ban of sales of all vaping commodities. There are still several other states that have ordained an emergency ban on time flavored e-liquids.

Juul came under particularly intense pressure. Its valuation slumped , its CEO resigned, it laid off hundreds of employees — all this as its home city of San Francisco was ordaining what amounted to a ban on all e-cigarette auctions.” This temporary moratorium wouldn’t be necessary if the Federal government departments had done its enterprise ,” said San Francisco’s metropoli attorney.” This is a decisive step to help prevent another contemporary of San Francisco children from becoming addicted to nicotine.” But what about the abrupt outbreak of vaping illness and demises — would banning Juul and other e-cigarettes fix that problem? Siegel didn’t think so.

SIEGEL: I think it’s extremely unlikely that any store-bought nicotine-containing e-cigarettes are involved in this outbreak.

Why was he so self-confident? Well, there were a number of clues — starting with what was happening in the U.K. Which was pretty much nothing.

SIEGEL: So far, I don’t know of any cases of respiratory failure that have been reported in the U.K. And that’s important because it tells us that it can’t be traditional e-cigarettes because those products have been sold in the U.K. and in other countries for a decade or more, and they haven’t had any problems. Something different is going on here.

So what was going on now?

SIEGEL: I think what is going on different is that we have a huge black market, especially for THC concoctions. And I think it’s those commodities that are predominantly responsible for the outbreak.

THC, if you don’t remember from chemistry class, is the primary psychoactive ingredient of cannabis. And the Core for Disease Control, in surveying the victims of the EVALI outbreak, had learned–

SIEGEL: The CDC has reported that nearly 89 percentage of the cases are attributable to THC or black-market vaping petroleums, whereas 11 percentage of the cases did not admit to using THC. Now that doesn’t mean that those cases were consequently attributable to nicotine e-liquids, for a number of reasons. The more important of which is that beings tend to underreport their smoke help, specially youth.

In other messages, it seemed these vaping deaths and injuries weren’t mainly being caused by e-cigarettes. Perhaps e-cigarettes had nothing to do with the outbreak. It’s important to note that all e-cigarettes, which are designed to deliver nicotine, are vapes; but not all vapes are e-cigarettes.

SIEGEL: There is a difference between the types of manoeuvres that can be used to vape cannabis as opposed to designs that can be used to vape nicotine-based liquids. These are very different types of liquids.

E-cigarettes use liquids that are generally ocean or alcohol-based, while THC vaping liquids are oils.

SIEGEL: The cannabis distillate actually needs an oil base to dissolve properly. You’re mostly talking about vaping oil versus vaping liquid. And the devices that can handle those types of liquids are quite different. And we’ve got to be very careful not to conflate the two.

But there was a lot of conflation going on between spray or alcohol-based nicotine e-cigarette maneuvers and oil-based vaping maneuvers. Not simply in the media reporting on the outbreak, but in how some state governments were approaching e-cigarette bans.

SIEGEL: First of all, their own policies I don’t think are justified because there’s no evidence that store-bought nicotine e-liquids are involved at all in this. So why set all these vape stores out of business when it’s not going to have any significant impact in curtailing the outbreak? But furthermore, there is going to be some severe negative public-health consequences of these prohibitions. Countless ex-smokers who are dependent upon vaping concoctions to stay off tobacco are going to switch to smoking when their commodities are taken off the shelves.

There are also the hundreds of millions of smokers in places like Indonesia and Russia and China who, if you’re rooting for public health generally, you might want to see have easy access to e-cigarettes. In the midst of all this came a couple of surprising developings. The Trump Administration and the FDA had been leaning toward implementing a outlaw of most flavored e-cigarettes in the hopes of curtailing youth vaping. But the White House then reversed itself. But Juul Labs, in the face of that expected spice banning, had already announced that it was discontinuing all its sweet and fruity nicotine cartridges — mango, cucumber, even its more popular, spate, all gone. The only flavors Juul would continue selling in the U.S. are menthol, “Virginia tobacco” and “classic tobacco.” Now, was this a public-health victory? Michael Siegel doesn’t think so.

SIEGEL: I think what a lot of parties don’t realize is there is no such thing as an un-flavored e-liquid. Every e-liquid has a flavor, it’s just that tobacco is something of those spices, and then there’s hundreds of other flavors.

So when the FDA was considering a ban on these spices — and that boycott may still happen, it’s hard to say — what was the idea behind that?

SIEGEL: The idea behind that, probably, is that youth are more likely to use the non-tobacco spices than the tobacco flavor. The difficulty with that is that so are adults. Adult smokers who have quit successfully utilizing these produces have predominantly abused flavored concoctions, and they specific don’t like the tobacco produce because it reminds them of cigarettes. The entire phase of swapping to vaping is to get away from the tobacco suffer, and so many vapers actually spurn the idea of using a tobacco e-liquid. So to take these spices off the market and to tell smokers, “Okay, well, just go back to the tobacco” — that’s just not is happening. What are the smokers was just going to do? They’re basically going to get two alternatives. Either they just go back to smoking or they try to obtain these products off the black market.

And what about younger vapers who’ve get accustomed to — or addicted to — flavored vaping?

SIEGEL: I feel a good deal of youth are going to transition from flavored e-liquids over to THC oils because those are the products that are going to be available. It’s incredibly easy to get these black-market THC products. You just go onto the internet. You say you’re 21. They will use what’s available. And what’s going to be available is going to transition towards THC petroleums. And that could actually stimulate the outbreak worse rather than better.

Because the outbreak, recollect, the deaths and injuries, seems to be not be driven by e-cigarette use.

SIEGEL: I reflect the strongest evidence is simply that in 90 percent of the patients admit to using THC, even though there’s a lot of underreporting, testing of the THC cartridges has uncovered Vitamin E acetate petroleum. And still further , not a single nicotine liquid that’s been measured has had any aberrations in it.

Indeed, in early November, the CDC affirmed it had identified what it considered a, mention, “very strong culprit” for the vaping deaths and injuries: Vitamin E acetate oil, as Michael Siegel had supposed. What is Vitamin E acetate petroleum? It’s a thicken part that’s recently begun present up in vaping liquids — particularly in black-market THC commodities that are thought to come primarily from China. So, to be clear, as of now it appears that most, if not all, of the deaths and illnesses were compelled not by e-cigarettes but instead by skimpy black-market THC commodities. But in the best interests — and in the course of carrying out a programme that seems to be driven more abstention than injure reduction — mood and city governments and some state health departments have already taken steps to curtail the availability of e-cigarettes. What does Michael Siegel think of this?

SIEGEL: I recollect from the perspective of legislators, this is a really easy way to be able to tell your ingredients that you care about kids. You care about health. You are out there restricting the flavored e-cigarettes. It’s very easy to do that because there is no opposition. The vaping manufacture doesn’t have a powerful foyer like the tobacco manufacture does. And what’s very interesting is that these same politicians who want to ban flavored e-liquids don’t want to touch cigarettes. They don’t want to have any increased restraints for the sale of tobacco. They don’t want to take tobacco off the shelves. So I is of the view that what they’re doing is basically exactly witnessing some practice that they are able to, without having to actually take any kind of politically gutsy act, make it look like they’re really taking a strong stance.

From the perspective of health districts I don’t think that they’re being insincere, I envisage their goals are to try to improve health, and I’m not inquiring that. What I do think is going on with the mood health agencies, though, is one of two things. I think that a lot of state health departments just take their direction from the CDC. They don’t want to conflict with what CDC says. And there are many health organizations that really have just been against e-cigarettes from the start. And they see this as an opportunity to take advantage of this outbreak, to advance their agenda of get e-cigarettes boycotted, or at least getting the spices banned. And in fact, many of the states are doing this through emergency guilds, bypassing the legislative process. And the problem with that is it infringes the breakup of supremacies.

Health districts is not have the authority to establish law. They’re supposed to enforce the law that the legislature sets out. What they’re doing is declaring an emergency because of the outbreak, and then responding by banning e-cigarettes that don’t have anything to do with the eruption. I don’t think that there are politics involved in what the territory health districts are doing. I think that these are dedicated professionals. I think they’re sincere. I think they’re well-intentioned. But I just think there’s an underlying bias that mass their thinking.

And how would Michael Siegel, if he left the ivory tower of academia for some large-scale public-health department that was wrestling over the future of e-cigarettes, how would he step the line between abstention and harm reduction?

SIEGEL: I foresee the most important thing that could be done to limit youth access to these products is to restrict the sale of not only e-cigarettes, but all tobacco produces, including real cigarettes, to stores that are only open to people who are over 21 years old and that simply sell tobacco products or e-cigarettes. Similar to the way we handle liquor in most states in the U.S. I envision a second thing that we need to do is to have direct regulations of e-cigarette marketing, and to allow companies to tell the truth to consumers — namely that this organization is concoctions that are designed for smoking cessation. And I consider one of the problems right now is, because companionships would not be able to even inform their consumers truthfully that people are using these products for smoking cessation, they have nothing to fall back on in their ads other than trying to start e-cigarettes or vaping examination glamorous.

At the moment , nothing of it is looking very glamorous.


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Here’s where you can learn more about the people and ideas in this episode 😛 TAGEND


Jonathan Gruber, economist at the Massachusetts Institute of Technology, and administrator of the National Bureau of Economic Research’s Program on Health Care. Dorothy Hatsukami, clinical psychologist at the University of Minnesota, and superintendent of the Tobacco Research Programs. Vivek Murthy, physician, and onetime United States Surgeon General. Michael Siegel, physician, and professor of society health sciences at the Boston University School of Public Health. Robert West, psychologist at the University College London, writer of the publication Addiction, and administrator of the Tobacco& Alcohol Research Group.


Different Doses, Spans, and Models of Delivery of Nicotine Replacement Therapy for Smoking Cessation ,” by Nicola Lindson, Samantha C. Chepkin, Weiyu Ye, Thomas R. Fanshawe, Chris Bullen, and Jamie Harmann-Boyce( Cochrane Database of Systemic Reviews, 2019 ). “JUUL Advertising Over its First Three Years on the Market ,” by Robert K. Jackler, Cindy Chau, Brook D. Getachew, Mackenzie M. Whitcomb, Jeffrey Lee-Heidenreich, Alexander M. Bhatt, Sophia H.S. Kim-O’Sullivan, Zachary A. Hoffman, Laurie M. Jackler, and Divya Ramamurthi( Stanford Research into the Impact of Tobacco Advertising, 2019 ). “Toxicological Comparison of Cigarette Smoke and E-Cigarette Aerosol Using a 3D in Vitro Human Respiratory Model ,” by Lukasz Czekala, Liam Simms, Matthew Stevenson, Nicole Tschierske, Anna G. Maione, and Tanvir Walele( Regulatory Toxicology and Pharmacology, 2019 ). “Health Effects in COPD Smokers Who Switch to Electronic Cigarette: a Retrospective-Prospective 3-Year Follow-Up ,” by Ricardo Polosa, Jaymin B. Morjaria, Umberto Prosperini, Cristina Russo, Alfio Pennisi, Rosario Puleo, Massimo Caruso, and Pasquale Caponnetto( International Journal of COPD, 2018 ). “Prevalence and Distribution of E-Cigarette Use Among U.S. Adults: Behavioral Jeopardy Factor Surveillance System, 2016 ,” by Mohammadhassan Mirbolouk, Paniz Charkhchi, Sina Kianoush, Iftekhar Uddin, Olusola A. Orimoloye, Rana Jaber, Aruni Bhatnagar, Emelia J. Benjamin, Michael E. Hall, Andrew P. DeFilippis, Wasim Maziak, Khurram Nasir, and Michael J. Blaha( Annals of Internal Medicine, 2018 ). “Chemical Composition of Aerosol from an E-Cigarette: A Quantitative Comparison with Cigarette Smoke ,” by Jennifer Margham, Kevin McAdam, Mark Forster, Chuan Liu, Christopher Wright, Derek Mariner, and Christopher Proctor( Chemical Research in Toxicology, 2016 ). “Inventing Conflicts of Interest: A History of Tobacco Industry Tactics ,” by Allan M. Brandt( American Journal of Public Health, 2012 ).


How to Make People Quit Smoking( Ep. 161 )” Freakonomics Radio( 2014 ).

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