Survey Suggests Lung Disease Misinformation Has Compounded Confusion About the Hazards of E-Cigarettes
If that confusion drives vapers back to smoking or discourages others from making the switch, it will have deadly consequences.
The percentage of Americans who understand that e-cigarettes are less hazardous than the conventional, combustible kind has fallen by 14 points since June 2018, according to a new Morning Consult poll. That shift is no doubt largely due to misleading warnings from public health agencies and irresponsible reporting by major news media outlets about recent cases of severe respiratory illnesses among vapers. Although the available information indicates that the vast majority of those patients used black-market cannabis products, the government and the press continue to blame their symptoms on "vaping" and "e-cigarettes" in general, leaving the false impression that legal nicotine products, which have been in wide use for years, pose a potentially deadly threat.
That message is dangerous for three reasons. First, it does not alert consumers to the specific threat posed by black-market THC vapes, so people who otherwise might have avoided them may continue to use them. Second, it drives former smokers who are now vaping back to a much riskier habit. Third, it deters current smokers from switching to an alternative that would dramatically reduce the health risks they face.
In the Morning Consult survey of 2,200 adults, which was conducted last week, 66 percent incorrectly said e-cigarettes are either just as dangerous as or more dangerous than conventional cigarettes. A similar poll conducted in June 2018 found that 52 percent of Americans endorsed that erroneous view. Meanwhile, the share who recognize that vaping nicotine is less dangerous than smoking has fallen from 36 percent to 22 percent. In last week's poll, 58 percent described "using electronic cigarettes" as "very harmful," up from 38 percent last year.
Public understanding of the relative risks posed by vaping and smoking was already declining before the lung disease scare, thanks to equivocating and sometimes outright false statements by anti-smoking activists and public health officials. Between 2012 and 2017, according to a study published last March, the share of respondents who correctly perceived e-cigarettes as less dangerous than combustible tobacco cigarettes fell from 51 percent to 35 percent in one survey and from 39 percent to 34 percent in another.
During that same period, the case for the harm-reducing potential of e-cigarettes became steadily stronger. In 2015 Public Health England endorsed an estimate that vaping is something like 95 percent safer than smoking. In 2016 the Royal College of Physicians concluded that "large-scale substitution of e-cigarettes, or other non-tobacco nicotine products, for tobacco smoking has the potential to prevent almost all the harm from smoking." Studies published in 2016 and 2017 showed that smokers who switch to e-cigarettes dramatically reduce their exposure to hazardous chemicals generated by tobacco combustion—as dramatically as smokers who switch to nicotine replacement products such as gum or patches (a finding confirmed by a 2019 study of Juul e-cigarettes, the dominant brand in the United States).
Misleading statements about "vaping-related" respiratory illnesses, which by the federal government's latest count include 530 cases and seven fatalities, seem to have widened the gap between what the science shows and what the public believes. That trend is unambiguously bad for public health, because it deters the shift from smoking to vaping, which Scott Gottlieb, former head of the Food and Drug Administration (FDA), described as "a tremendous public health opportunity."
The Morning Consult poll found that 58 percent of respondents, based on what they had "seen, read, or heard on the news lately," believed people had "died from lung disease" caused by "ecigs, such as Juul," compared to 34 percent who said the cases involved "marijuana or THC e-cigs." According to a tally by the Competitive Enterprise Institute's Michelle Minton, the seven fatalities include four cases where the patient was known to have vaped THC and three where the product used by the patient has not been reported.
More generally, the available information indicates that the overwhelming majority of patients with respiratory illnesses had vaped THC: 83 percent in Illinois and Wisconsin, 90 percent in Utah, 92 percent in Iowa and New Mexico, and 100 percent in Colorado, Nebraska, New York (among patients who submitted products for testing), and North Carolina. Since patients may be reluctant to admit illegal drug use, the actual percentages in some of these states could be higher.
How did people get the impression that "ecigs, such as Juul," are implicated in these cases? From misleading reporting, such as a recent story in the Dallas Morning News that says "more than a dozen individuals—mostly young people—have been hospitalized in Dallas County hospitals with severe respiratory problems that health officials believe are part of the nationwide outbreak linked to vaping." The story blames "vaping" in the headline and in the first and second paragraphs. The seventh paragraph mentions possible "restrictions on the sale of e-cigarettes" and the pending FDA ban on "flavored vaping cartridges." The ninth paragraph notes "a bill to license vaping stores" and the recent increase in the minimum age to purchase tobacco and e-cigarettes in Texas. Not until the 11th paragraph do readers learn that "ninety percent of the Dallas County cases reported vaping THC products."
THC products are illegal in Texas, and most of these patients are "young people," so the true percentage may be even higher. Even when patients are completely candid, they may not know what they actually vaped if they bought cartridges on the black market. Yet the Dallas Morning News leaves the impression that these cases have something to do with legal e-cigarettes and legal vape stores.
News outlets are taking their cue from public health agencies such as the U.S. Centers for Disease Control and Prevention (CDC), which is still delivering a muddled message about respiratory illnesses associated with vaping. "We do not yet know the specific cause of these lung injuries," the CDC says. "The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases."
As Boston University public health professor Michael Siegel notes, that position is at odds with the CDC's usual practice. "The CDC has continually downplayed the role of THC vape carts in the outbreak and…continues to blame it on electronic cigarettes generally," he writes. "I defy you to find a single other CDC outbreak investigation in which the agency emphasized that 'the investigation has not identified any specific exposure that is linked to all cases.' The failure to find a 100% link between a single exposure and every single case is the norm in outbreak investigations and never precludes the CDC from concluding that a highly common exposure is a likely source. Except in this investigation."
Siegel notes that the CDC did not hesitate to draw conclusions about "an outbreak of severe ocular and respiratory illness following exposure to a contaminated hotel swimming pool," even though "only" 83 percent of the patients "reported spending time in the pool area." Nor did it temporize about "a Salmonella outbreak caused by contaminated beef sold in the U.S.," even though "only" 93 percent of the patients reported eating beef purchased in this country. In those cases, a strong association between a disease and a potential hazard was enough for the CDC to issue clear warnings.
Based on the publicly available information, we know that the overwhelming majority of patients with respiratory symptoms have admitted that they used black-market cannabis products (or what they thought were cannabis products). Without blood or product tests, we have to rely on self-reports, which almost certainly understate illegal drug use, especially by teenagers and young adults. The leading theory among state and federal investigators is that additives or contaminants in illicit THC vapes (and possibly also in counterfeit nicotine cartridges) are to blame for these illnesses. One plausible culprit is vitamin E acetate, which was detected in most samples of THC fluid tested by the FDA and New York's state lab.
Despite all of that evidence, journalists and public officials continue to insinuate that using legal nicotine products such as Juul might kill you. The result is that Americans, who already were confused about the health risks of vaping, are even more confused. If that confusion drives vapers back to smoking or discourages others from making the switch, it will have deadly consequences.
