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Posted on September 20, 2019 at 6:56 PM

by Craig Klugman, Ph.D.

Over 530 (as of 9/17) users of e-cigarettes have been stricken with a vaping-related lung illness and 8 people have died from this new affliction.  The reports span 38 states and the U.S. Virgin Isles. The FDA and CDC have begun investigations into these lung illnesses resulting in a September 10 letter to Juul—a large manufacturer of e-cigarettes and cartridges—that they violated federal law by stating their product is “safer” than other forms of tobacco.Walmart announced that they will cease selling vapers. And in July 2019, a judge ruled in a  legal case brought by the American Academy of Pediatrics, American Heart Association, American Lung Association, and other medical groups that vaping companies have until May 2020 to have their products approved by the FDA.

The modern vape pen is attributed to a Chinese pharmacist, Hon Lik, in 2003. The devices were first available in the U.S. in 2007. A vaperor e-cigarette is a handheld, battery-operated unit that simulates smoking by delivering a dose of nicotine via an infused e-liquid. “Vape” is short for vaporizing, whereby the liquid is aerosolized to deliver the nicotine via a noncombustible system. Public health experts hypothesize that vape-related lung illness may be caused by chemicals used in the liquid (propylene glycol, glycerin, among others) or in the infusion process.

Art by Craig Klugman

E-cigarettes and vaping were introduced as a “healthier” alternative to smoking tobacco cigarettes. The idea (and marketing) followed a public health harm reduction model, get people to do something less often or convert to a less dangerous form of the activity. After years as a “safer” alternative to smoking, it has actually created many new users of e-cigarettes. Of high school students, over 3.6 million (21 percent) vape. Ninety percent of adults who vape are former or current cigarette smokers but 40% of vapers aged 18-24 are new to tobacco ingestion. A Johns Hopkins report estimates that nearly 11 million people in the U.S. regularly use vapers. The devices are most popular with people under 35 and sexual minorities. The market is estimated at nearly $20 billion worldwide.

The Trump Administration plans to introduce a ban on flavored vape products, as many cities have done, because these are more appealing to children. In 5 states, one needs to be 21 years of age or over to purchase while in 3 states the purchase age is 19 and in the remaining 42 states, 18 years of age. In the U.S., vaping is seen as a public health crisis, but across the pond in the U.K. (where there has not been an outbreak of lung disease), vaping is accepted as a way to get a quick toke that is safer than traditional cigarettes.

In the bioethics world, there has not been a lot of work on the ethics of vaping. Some health law scholars have followed the regulatory developments on the issue. A 2016 article out of McGill University proposed a variety of “ethical considerations”. The article talks about the risk/benefit ratio of “safer than cigarettes” (i.e. harm reduction) vs the harm of smoking anything. The authors also raise concerns about how these devices would be regulated and that there is a lack of random-controlled studies showing that vaping helps people to cease tobacco use. They express concern that these products might expose more people to the dangers of tobacco use and smoking who would not have picked up a cigarette, including children and young adults who could be influenced by glamorous advertising. Could vaping pens be creating new addicts? In addition to regulation and efficacy, they also expressed interest in how vaping would change popular culture by “renormalizing smoking”. Their last point was about conflicts of interest since the tobacco (i.e. cigarette) industry is embedded in the vaping industry.  For example, the brand VUSE is owned by Reynolds America.

A number of analogies have been made to cigarette smoking and the thirty years of campaigns to reduce ingestion of that form of tobacco. That approach also adds some intriguing areas for research and thought when it comes to the bioethics of vaping. For example, should physicians be asking their teenage and young adult patients about their vaping habits? Can insurers charge vapers more for health and life insurance? Is a harm reduction strategy (the first market for vapers) effective or should we take a zero-tolerance approach? Might an employer forbid their workers from vaping both on and off the job in part because such behavior might affect insurance rates or be a nuisance to others?

Restricting use of vapes in adults might be a violation of autonomy (including the right to make bad choices and choices that injure oneself). The effort to curb and make unpopular cigarette smoking was based in part on the need to protect others from harm as more important than an individual’s choice to smoke (i.e. harm from second-hand smoke). If vaping only injures the user but not others, it might be harder to make an argue to limit use around others. Thus, are there health effects to second hand vaping that would justify restricting where it should be permitted (not in public spaces, not in closed cars, etc.)?

A consensus has built that minors should be not vaping, a stance that is reflected in laws that restrict purchases by minors, and in some places those under 21. Such efforts could be further supported with restrictions on vape advertising which currently exists for cigarettes but not for vapers. Another challenge is enforcing bans and restrictions on vaping and advertising Currently, vaping products only carry an FDA nicotine addictiveness warning. Also, identifying people who vape in restricted places (for example in offices, classrooms) can be difficult to identify as  the smoke can have no scent and the vape pens are sometimes designed to look like writing pens, UBS drives, or other small, common instruments.

What has quickly become a public health crisis in the U.S. has not stimulated much interest in the bioethics community. This growing influence in popular culture and potentially dangerous product could benefit from a bioethics lens in terms of how society and legislatures respond to this challenge.

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