The misinformation driving Multnomah County’s flavored vape ban
On Wednesday I published an op-ed in the Oregonian opposing a proposal from the Multnomah County Commission to ban the sale of all flavored tobacco and nicotine products, including e-cigarettes. I squeezed as much as I could into my 650-word limit, but obviously had to leave a lot out. There were two issues in particular I wasn’t able to address there and a relevant academic paper that came out this week, so this a post to dig into those issues more deeply. (But read the op-ed first if you haven’t!)
The primary motivation for banning flavored nicotine products is to prevent non-smokers, and especially youth, from taking up the habit. This is in tension with the goal of encouraging adult smokers to switch to safer products and displace combustible cigarettes from the market. How to balance these trade-offs is a complex topic that people disagree about in good faith. But other aspects of this debate are badly misinforming the public about the relative risks of smoking and vaping.
Vaping and COVID risks
“After two years of a deadly respiratory virus that is exacerbated by smoking, I am personally ready to say enough,” chair Deborah Kafoury says of the ban. And from the commission’s website:
In an important part of Tuesday’s briefing, Multnomah County Health Officer Dr. Jennifer Vines told the Board of Commissioners that tobacco and COVID-19 have “serious interplay,” explaining that smokers who were hospitalized with COVID-19 were linked to higher risks of complications and death.
There are two big problems with these claims. One is that the evidence on smoking and COVID is much more ambiguous than Vines indicates. The second is that even if the evidence were clear, it pertains only to smoking; it provides no justification at all for banning vapor products.
Vines draws her data from this paper published in July, which concludes that smoking is associated with worse outcomes from COVID among hospitalized patients. Is this an interesting finding? Sure. Does it tell us anything about vaping? No.
Because it’s very plausible that vaping and smoking have different impacts on COVID outcomes, a useful study on the question would have to separate vapers from smokers. This one does the opposite: “Patients who reported smoking or the use of e-cigarettes (vaping) were categorized as smokers.” Further, there were only 41 vapers in the entire sample of 2,239 smokers. Whatever the merits of the study, it just doesn’t say anything at all about vaping and COVID and shouldn’t be cited to justify a product ban.
That’s just one paper though, and it appears to have been cherry-picked by Dr. Vines to support her conclusion. The academic literature on this is actually much more interesting, conflicting, and counterintuitive than what she presented to the commission. As just one example, here are the results of a much larger cohort study that was just published two days ago:
Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06–1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04–1.11).
If I wanted to cherry-pick a study to argue against a ban, this would be a great one. It uses a large sample, it’s well-conducted, and it finds no significant difference between current smokers and never smokers on COVID outcomes. That’s surprising! But that’s also why one shouldn’t rely on individual studies to decide on sweeping product bans. You need to get an overview of the whole literature.
I’ve been following this topic throughout the pandemic and here’s how I’d summarize the findings:
- The one clearly consistent result is that former smokers are at higher risk of adverse COVID outcomes. This is not surprising and indicates that a history of smoking puts patients in a worse position when they get sick.
- The results for current smokers are more ambiguous. As in the study I mentioned above, some research finds that they defy the expectation of suffering worse outcomes compared than never smokers. More intriguingly, many studies find that smokers are less susceptible to infection in the first place. This is a very unexpected finding but it has been replicated surprisingly often. How to explain this is an unsettled question.
- There’s not much evidence at all on the relationship between COVID and vaping.
I’m just a journalist (albeit a very informed one) so I don’t ask anyone to simply take my word on this, but see also this recent review in the Lancet which notes many of the same ambiguities, including the inability to say anything conclusive about vaping and COVID.
To close this out, I’ll mention the best study I’m aware of that explicitly addresses vaping and COVID. It draws on a very large sample from the Mayo Clinic and explicitly differentiates between never smokers, former smokers, current smokers, vapers, and dual-users. The results: “Patients who used only e-cigarettes were not more likely to have a COVID-19 diagnosis (OR 0.93 [0.69–1.25], P = .628), whereas those who used only cigarettes had a decreased risk (OR 0.43 [0.35–0.53], P < .001).” If Dr. Vines wanted to present the commission with data relevant to an e-cigarette ban, this study is a much better fit than the one she chose — but it wouldn’t have helped her political advocacy.
However the science on these questions eventually shakes out, it’s ultimately unlikely to provide compelling reasons to change policy on e-cigarettes. Whatever the marginal risks might be associated with vaping and COVID, they are swamped by the much greater potential for e-cigarettes to reduce deaths caused by smoking. Taking advantage of the COVID pandemic to concoct weak justifications for prohibition is both cynical and fails to engage seriously with the aims of harm reduction. What I wrote when I first covered this topic for Slate in April of 2020 remains true:
It’s possible that vaping may marginally increase the risks of COVID-19; it’s also possible that exaggerating fears will harden public attitudes against vaping, discourage smokers from switching, and lead to even more restrictions on e-cigarette products. These possibilities highlight the danger of politicizing science and taking advantage of a frightening illness to promote a preexisting agenda. Policies put into place during a once-in-a-lifetime pandemic are unlikely to be accurately informed by long-run considerations, but their effects will last beyond the current crisis.
Vaping and lung injuries
I wasn’t at the recent presentation to the commission, so I don’t know to what extent the 2019 outbreak of lung injuries was discussed there. However, the commission’s website does cite “an outbreak of vaping-related lung disease” as motivation for its previous attempt to ban flavored products. And the Portland Mercury reports:
Multnomah County considered a ban on flavored e-cigarette liquids and tobacco products in late 2019 following a series of severe vape-related lung infections throughout Oregon and the nation. Nationally, nearly 70 people died of a vape-related fungal infection of the lungs.
The ban didn’t pass in 2019, which is good because as was evident then and even more obvious now, the outbreak of lung injuries was caused by additives to mostly-illicit cannabis products. (The Mercury’s reporting here is terrible since it does not mention cannabis, incorrectly implies that nicotine vapes were the cause, and describes chemical injuries as a fungal infection.) Unfortunately, the public perception of these events is much as the Mercury describes, so it needs to be addressed in any discussion of proposed prohibitions.
Clive Bates has written a really great explainer that’s worth reading for understanding the so-called “EVALI” outbreak. It’s now very clear that the primary cause was vitamin E acetate, a toxic additive that was used to thicken THC liquid to make it appear more potent. It’s not used in nicotine e-cigarettes, since it would serve no purpose in them and does not mix with nicotine vaping liquids. Unlike in cannabis vapes, no ingredient in nicotine e-cigarettes has been implicated in contributing to this wave of lung injuries.
Still, not every EVALI patient admits to vaping cannabis, so many speculate that nicotine e-cigarettes actually were causing these injuries. The problem with this idea is that it leaves open a lot of very hard to answer questions and requires many improbable coincidences. In brief: What was the additive causing harm? Why did it appear in the same time period and same geographic area as the injuries caused by cannabis vapes, and not in the previous decade in which millions of people vaped nicotine around the world? And why did these injuries stop happening at the same time that vitamin E acetate was removed from cannabis products when no change was made to nicotine e-cigarettes?
While it’s impossible to prove a negative, the fact is that no ingredient in e-cigarettes was ever identified to cause these lung injuries, no changes were made to e-cigarettes that would explain why the geographically limited outbreak began and then faded away, and it would be a remarkable coincidence if there was some dangerous contaminant in the supply that just happened to occur in the same times and places as those affecting the unrelated cannabis market. This doesn’t mean that no one, anywhere, has ever suffered adverse reactions to an e-cigarette, but the deadly EVALI outbreak is more plausibly explained by the fact people are not always forthcoming about their marijuana use.
Nonetheless, the lung injury outbreaks were a boon for activists looking to demonize e-cigarettes. The misleading communications from health professionals did lasting damage to the accuracy of the public’s perceptions of vaping. Numerous surveys have found that following these incidents, more respondents believe that e-cigarettes are more harmful or as harmful as conventional smoking, a major setback to the goals of tobacco harm reduction. It also led to bad policy, such as bans like the one proposed in Multnomah County that would force countless safer sources of nicotine off the legal market while leaving deadly cigarettes freely available. (Read my article in Slate on this from 2019, explaining now misperceptions of risk following scary events can lead to bad policies and more avoidable deaths.)
Much like the unsubstantiated concerns about vaping and COVID, the outbreak of lung injuries caused by contaminated cannabis products provides no justifications for prohibiting flavored e-cigarettes. There is a lesson here for the commission to consider, however. The EVALI outbreak was largely the result of prohibition and illicit markets. One study calculated that the risks of lung injury were three times higher for users in states that prohibited recreational cannabis than in states that allowed it.
Oregon provides a useful example. Once vitamin E acetate was identified as a contaminant, the Oregon Liquor and Cannabis Commission banned its use in inhaled cannabis products. That’s the kind of thing you can do when you have traceable supply chains and regulated markets. I think it’s unlikely that we’ll see similarly dangerous additives added to nicotine e-cigarettes, but forcing them into illicit markets will guarantee that if it ever does happen, the problem will be much harder to address.
Wrapping up
The field of tobacco control is deeply divided, which makes it difficult for policymakers to get accurate information about vaping. Advocates for prohibition often speak the loudest, aided by frightening events like the epidemic of lung injuries and a global pandemic (and, sometimes, hundreds of millions of dollars from Michael Bloomberg). The arguments for harm reduction are more nuanced and get much less attention in the press, but they are put forth by some of the most reputable academics studying the question.
I mentioned it in my op-ed, but it’s worth quoting at length from the fifteen past presidents of the Society for Research on Nicotine and Tobacco who warned recently that the singular focus on youth vaping is undermining the potential to save smokers’ lives through harm reduction. I’ll give the last word to them and urge the local commissioners to give their advice serious consideration:
While evidence suggests that vaping is currently increasing smoking cessation, the impact could be much larger if the public health community paid serious attention to vaping’s potential to help adult smokers, smokers received accurate information about the relative risks of vaping and smoking, and policies were designed with the potential effects on smokers in mind. That is not happening.
The need to pay attention to adult smokers is particularly important from a social justice perspective. African Americans suffer disproportionately from smoking-related deaths, a disparity that, a new clinical trial shows, vaping could reduce. Today’s smokers come disproportionately from lower education and income groups, the LGBTQ (lesbian, gay, bisexual, transgender, and queer or questioning) community, and populations suffering from mental health conditions and from other drug addictions. Smoking accounts for a significant proportion of the large life expectancy difference between affluent and poorer Americans. For smokers with serious psychological distress, two thirds of their 15-year loss of life expectancy compared with nonsmokers without serious psychological distress may be attributable to their smoking. Vaping might assist more of these smokers to quit.
To the more privileged members of society, today’s smokers may be nearly invisible. Indeed, many affluent, educated US persons may believe the problem of smoking has been largely “solved.” They do not smoke. Their friends and colleagues do not smoke. There is no smoking in their workplaces, nor in the restaurants and bars they frequent. Yet 1 of every 7 US adults remains a smoker today.
Smoking will claim the lives of 480 000 of our fellow citizens this year alone.
