Anti-Vape Laws Could Do More Harm Than Good

Since July, a mysterious vaping-related lung illness has swept the country, sickening more than 2,200 people and killing 48. As the illnesses and deaths proliferated, so too did vaping bans. The city of San Francisco had already banned e-cigarette sales, and by September Massachusetts outlawed all e-cigarettes, followed by prohibitions against vaping products in Michigan, Rhode Island, and New York.

There was just one problem: The laws applied to nicotine e-cigarettes. But researchers discovered last month that this lung disease seemed to be the result of Vitamin E acetate, an ingredient found primarily in black market vapes containing THC, the main psychoactive chemical in marijuana.

So the “prohibitionist” policies that ban e-cigarettes just might be doing more harm than good, argue a group of public health experts in an opinion piece published today in Science. Author Amy Fairchild, dean of Ohio State University’s College of Public Health, and coauthors argue that policymakers, in their rush to address the surge in lung illnesses and teen vaping, may be depriving millions of adult smokers of a safer alternative to combustible cigarettes. They call for policies that are cautious but, she says, “not alarmist.”

When used—and regulated—appropriately, she argues, e-cigarettes are a form of harm reduction, just like 1980s exchange programs that allowed injection drug users to swap dirty needles for clean ones and reduce their chances of contracting HIV through shared needles. At the time, critics worried that providing free needles would endorse drug use or make it easier for children to get hooked. The end result, though, was that infection rates dropped precipitously. “The known harms of HIV were so great that the policy decision was made that this was a risk worth taking,” says Fairchild. “The same calculus is at work here.”

Cigarettes kill nearly 500,000 Americans every year, and the Centers for Disease Control estimate smoking costs the US more than $300 billion annually in medical bills and lost productivity. These risks are well known, while the long-term health consequences of vaping e-cigarettes are not as well understood. E-cigarettes certainly aren’t harmless; they still contain nicotine, which is highly addictive, and they can also include toxic flavorings, heavy metals, and carcinogenic chemicals. “There is no question that e-cigarettes are not safe,” says Fairchild. “But it’s a question of proportionate risk.” Instead of waiting for a perfectly safe product to replace cigarettes, these experts suggest, let’s allow smokers to choose the lesser of two evils.

“We’d rather everyone quit nicotine completely,” agrees coauthor David Abrams, a public health expert at New York University. “But if they’re going to use it, I’d much rather they use a less harmful product.”

Abrams points to research including a 2019 study conducted in the United Kingdom that found e-cigarettes were more effective than other methods at helping people quit smoking. E-cigarettes deliver nicotine efficiently, so they meet people’s cravings better than lozenges or medications. That addictive quality actually helped smokers stick with the vape instead of going back to regular cigarettes. Users also enjoy the flavors, which make the experience more enjoyable than smoking.

But those same attributes are also what have made e-cigarettes so attractive to teenagers. While teen smoking rates are at record lows, teen vaping is soaring. The 2019 National Youth Tobacco Survey found more than five million teenagers use e-cigarettes, often daily. It’s a Catch-22, says Abrams: A really appealing, high-quality e-cigarette is going to be a more effective substitute for combustible cigarettes—but it’s also going to be more addictive and appealing to teens.

For Abrams, the promise of eliminating tobacco cigarettes is worth the potential risks. But not all public health advocates agree. “The recent lung illness outbreak has alarmed physicians and the broader public health community and shined a light on the fact that we have very little evidence about the short- and long-term health consequences of e-cigarettes and vaping products,” Patrice A. Harris, president of the American Medical Association, wrote in a public statement. The organization calls for a ban on all vaping products. Similarly, the American Cancer Society doesn’t recommend e-cigarettes as a good option to stop smoking and suggests that anyone who has switched from traditional to e-cigarettes should find a way to stop smoking altogether “as soon as possible.”

Another unintended consequence of the bans would be if the new laws drive current e-cigarette smokers—including teenagers—to the black market, which is likely to be more dangerous. The current lung illness outbreak seems to be primarily caused by adulterated or contaminated black-market THC products.

Abrams, Fairchild, and their coauthors advocate for a more measured approach: Leave e-cigarettes on the market but regulate them strictly. Fairchild suggests increasing the purchasing age, now 18 in many states, to 21. She also advocates taxing e-cigarettes, which would put them out of reach for many cost-conscious teens. In the past, both methods worked to curb youth smoking.

To prevent outbreaks of lung disease, the Food and Drug Administration should also carefully monitor e-cigarettes to make sure the ingredients are safe and that nicotine levels aren’t dangerously high.

The UK uses similar restrictions and also controls how vaping devices are packaged and marketed. That seems to have worked: Unlike the experience in the US, there is no teen vaping epidemic in the UK, and no proliferation of black market products.

In any case, prohibition ultimately may not be the most effective strategy. Kids don’t just smoke e-cigarettes because they taste good, points out Michael Siegel, a public health researcher at Boston University who wasn’t involved in the paper: “They’re vaping because vaping is cool.” Banning products won’t stop kids from wanting to use them, or from getting their hands on them.

Siegel recommends looking to tobacco for a few clues on how to deal with vaping. Although the US currently has the lowest smoking rates in its history, the nation has never banned cigarettes, he says. Instead, anti-smoking advocates changed people’s habits by passing age restrictions and taxes, but also by changing the culture. The Truth Campaign portrayed tobacco companies as manipulative entities that took advantage of teenagers. Not smoking became a cool form of anti-corporate rebellion. To pull off such a complete cultural reversal, anti-vaping advocates may want to think less about changing lawmakers’ minds—and more about convincing teens. Maybe a viral TikTok is in their future.