Regulate, but don’t ban, flavored e-cigarettes

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A new drug epidemic is sweeping across youth in our nation’s schools and colleges. These products come in attractive flavors like banana split, birthday cake, cotton candy and bubble gum. Its use has been linked to an outbreak of severe respiratory failure that has affected 1,300 people and resulted in 26 deaths. The use of this drug among college students has reached a 35-year high.

If you think we are talking about electronic cigarettes, you are wrong. The drug that is ravaging the health of youth and young adults across the nation is marijuana. 

According to a warning from the Food and Drug Administration (FDA), vaping cartridges containing THC, especially those obtained off the black market, are linked to more than 1,000 cases of severe lung injuries, mostly among previously healthy youth and young adults. 

Due to the decrease in perceived harm from marijuana because of its legalization in many states, the rate of marijuana among college students reached a 35-year high in 2018 and the proportion of college students who vape marijuana more than doubled just from 2017 to 2018. 

While politicians and policy makers have been busy trying to address the problem of nicotine intake among youth due to their vaping of electronic cigarettes, the problem of youth vaping of marijuana has swept across the nation under their noses. 

While six states have now banned the sale of either all electronic cigarettes (Massachusetts) or all flavored e-cigarettes (Michigan, New York, Oregon, Rhode Island and Washington), it is not nicotine products but THC vaping products that are now almost definitively linked to the outbreak of severe, acute respiratory disease. 

Almost uniformly overlooked by policy makers is the fact that most youth who regularly vape are using not only nicotine, but also THC-containing e-liquids. Based on my analysis of data from the 2018 National Youth Tobacco Survey, of current youth e-cigarette users (those who used in the past 30 days), 51.9 percent report having vaped marijuana or THC. Of regular youth e-cigarette users (those who used at least 10 days in the past 30 days), 63.1 percent report having vaped marijuana or THC.

While the ingredients in nicotine-containing e-liquids sold in retail stores are known—they are both listed on the label and registered with the FDA — there is no way to know what is present in THC vape cartridges purchased off the street.

In fact, one possible cause of the respiratory disease outbreak is the secret introduction of a new thickening agent — vitamin E acetate oil — into black market THC oils starting in late 2018. A severe lung illness virtually identical to the current outbreak was reported back in 2000 and was attributed to the use of THC oil.

The critical point that policy makers now need to realize is that this devastating respiratory disease outbreak is not occurring because youth are obtaining flavored e-liquids from retail stores, but because they are purchasing flavored THC oils off the black market.

The kid-friendly flavors of THC oils that can easily be bought online must be enticing to young people. So much focus has been placed on gummy bear e-cigarettes that these black market marijuana vapes have completely escaped our attention.

The most important lesson here is that unregulated markets pose an enormous risk for the widespread dissemination of contaminated and potentially deadly products. When a product is in high demand, simply banning the product may do more harm than good as it simply relocates the product from a regulated legal market to an unregulated black market. A more effective approach is to strictly regulate all aspects of the product’s manufacturing, sale and marketing.

The problem of youth electronic cigarette use must be addressed, but the states which have banned flavored e-liquids are taking the wrong approach.

Ironically, in May 2020, when the FDA regulation of nicotine-containing e-cigarettes goes into effect, the states which have banned flavored e-cigarettes will be the only ones in which flavored e-liquids consumed in their state are completely unregulated. Banning flavored e-cigarettes is a flawed approach because it will create a new black market for flavored e-liquids. If that happens, we can expect to see more disease outbreaks like the one we are currently experiencing. 

Addressing the problem of youth e-cigarette smoking requires strict regulation, not prohibition. Congress should require the FDA to start by regulating the nicotine level allowed in e-cigarettes and by restricting their sale to stores which only sell tobacco and vaping products and only allow adults ages 21 and older. 

At the same time, Congress needs to follow the recommendation of former FDA Commissioner Dr. Scott Gottlieb by re-classifying marijuana so it is not treated as a controlled substance and by giving the FDA the authority to crack down on the black market sale of cannabis products.

Dr. Michael Siegel is a professor in the Department of Community Health Sciences at the Boston University School of Public Health. He testified in Congress Wednesday on strategies to address the youth vaping epidemic.

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