October Journal Club Review, the Vaping Crisis: Mysteries and dangers

October’s journal club was led by Amanda Hurley (Postdoc in Plant Pathology). Journal club review was written by Chris Unterberger (Graduate Student in Pharmaceutical Sciences).

Several months before Halloween 2019, a spooky new killer emerged from the shadows: vaping. Vaping has become a popular source of debate and discussion as of late due to the rise in mysterious, lung-related ailments and deaths. As of November 5, 2019, the number of reported cases of vaping-associated lung injuries was 2,051 in the US across every state except Alaska. The interest in youth vaping has also been a topic of recent legislation at local, state, and federal levels, as the number of teenage vapers has risen since the introduction of this technology to the U.S. in 2007.  Electronic cigarettes (e-cigarettes, e-cigs) have transformed from a “healthy” alternative for smokers who wanted to quit a bad habit to a deadly fad that has gripped the nation’s youth. 

The History of E-Cigarettes and Vaping vs. Aerosolizing 

Advertisements for e-cigs appeared in 1887, and the earliest patent for an electronic vaporizing device is from 1927. However, it was not until 2003 that the first patent was filed for the modern electronic smoking mechanism. The technology remained foreign to the United States until 2007 when the US patent was filed. First designed and marketed as an alternative to smoking tobacco, the physical designs of these devices have shifted from mimicking cigarettes to a more discrete form that  often resemble flash drives. Though initially wary of the “fad” that was e-cigarettes, large tobacco companies eventually took advantage of the enthusiasm by acquiring the small companies that initiated the spread of the vaping craze. Companies such as blu eCigs, Vuse, and MarkTen were bought out by tobacco companies Imperial Tobacco, R. J. Reynolds Tobacco Company, and Altria, respectively

“Vaping” has actually been incorrectly dubbed; it is the action of inhaling an aerosol containing various chemicals which include nicotine, THC (the psychoactive chemical found in cannabis), and/or other potentially toxic chemicals. This aerosol, which is not a vapor, is produced by heating a liquid stored in a cartridge within devices such as e-cigarettes and vape pens. 

A Vaping Health Crisis 

The drastic increases in illnesses and deaths associated with vaping is considered a crisis by many.  In April 2019, the first vaping-related lung injuries were reported by the state health departments of Illinois and Wisconsin. August 23rd, 2019 saw the first vaping-associated death. By the end of October the total vaping-associated death count had reached 37. Symptoms of vaping-induced lung injury experienced in these cases ranged from chest pain and coughing to vomiting and diarrhea, which could develop over time or occur suddenly. Collectively and contextually, these symptoms can be categorized as acute respiratory distress syndrome that ultimately leads to the need for breathing apparatuses or death. 

Exploring the Mechanism of the Crisis 

The vaping phenomenon caught the eyes of academics and medical researchers. Early research interests focused on e-cigarettes’ ability to prevent tobacco cravings and withdrawal symptoms. Recently, the research focus shifted to the safety of vaping. The mechanism behind the cause of vaping injuries and deaths has not been fully described, though some general theories have been proposed. The first of the two general theories that I will describe is a fascinating one: oil heating. The mechanism behind this theory is that the nicotine solution in e-cigs contains oils that, when inhaled, coats the lungs and causes inflammatory damage and injury. This theory aligns with the new reports suggesing that Vitamin E acetate may play a role in fatal vaping injuries.

The second proposed mechanism of vaping-related disease is the inhalation of contaminants. Bacterial and fungal contamination has been found in vaping products, which can lead to injurious pulmonary inflammation when inhaled. Though the components of commercial vaping cartridges and their associated aerosols are typically thoroughly inspected, unregulated cartridges, especially in the case of cartridges containing THC, inhabit the black market. These cartridges may contain contaminants that are dangerous or even fatal when inhaled. Another possibility of regulatory ineptitude is in the popular flavored vape cartridges. Though the flavor additives found in the aerosols of flavored cartridges are approved for use in food, the effects of inhalation have not been fully studied and may be a source of danger

The (Un)Regulation of E-Cigarettes 

E-cigarettes are not legally cigarettes and have been difficult to regulate. When the Tobacco Control Act was signed into law in 2009, the FDA gained authority to regulate the manufacturing and distribution of tobacco products (prior to regulation by the FDA, there were even no rules limiting the sale of e-cigarettes to minors). There was an immediate dispute, however, over whether tobacco products included e-cigarettes, which were often referred to as a “drug-delivery devices.” Legal battles ensued over the FDA’s authority to regulate e-cigarettes at all. The FDAwas pressured by outside special interest groups—anti-vaping advocates and big tobacco companies—to create new regulatory guidelines on the vaping market, suffocating its ability to thrive in the US. These new guidelines, dubbed the Deeming Rule[s], forced vape manufacturers to apply for premarket tobacco product applications (PMTAs) in order to be eligible for sale in the US. These PMTAs required them to prove their safety and efficacy as a non-cigarette alternative to smoking. Modifiable e-cigarettes were subject to further scrutiny; manufacturers had to prove that all modifiable elements were safe, further inhibiting the vaping market. The original PMTA deadline in 2018 was pushed back four years by the previous head of the FDA, Scott Gottlieb, allowing vaping to continue unregulated for an extended period. 

The FDA’s struggles with regulating e-cigarettes and preventing teen use hasn’t stopped state and territory legislators from acting. As of October 14, 2019, San Francisco, Michigan, New York, Massachusetts, Rhode Island, Washington, Oregon, Montana, and the Pine Ridge Reservation have put temporary bans on e-cigarettes and/or their flavored counterparts. Companies such as Walmart and Rite Aid have joined in this fight by discontinuing sales of e-cigarettes. Juul Labs halted sales of mint-flavored vape cartridges in the US in response to teenage consumption of flavored products. The FDA could be the next group to enforce a ban on flavored products after failing to do so in 2016

What Now? 

Scientific research is continuously exploring the mechanism of vaping-related disease, injury treatment, and prevention. Additionally, the assumption that e-cigarettes can safely serve as a smoking alternative is being reevaluated following the recent string of vaping-related deaths.

E-cigarettes entered the US without a clear regulatory umbrella. The FDA needs to establish a thorough and separate mechanism of regulating e-cigarettes apart from their non-electronic cousins. With clear regulations  the FDAcan determine if flavoring is harmful or illegally enticing to youth. Further, clear regulations will guide the safety standards that govern other food and drug consumables in the US market, potentially legitimizing e-cigarettes as a safe product.

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