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A selection of flavored vaping liquids.

About six months ago I talked about the health risks of vaping, and the youth vaping epidemic in my post “Vape Nation: Vaping is Bad, Kids“.> Today I want to follow up by looking at the outbreak of vaping-related pulmonary illness, the flavored e-cigarette bans, and finally what I think is bad behavior on the part of public school administrators in response to the youth vaping epidemic.

Vaping related respiratory illness

Over the past month or so there has been an explosion of respiratory illnesses related to vaping. New cases are being reported so quickly I’ve had to change my numbers three times now and I’ve been working on this post for less than two weeks. Things really kicked off on August 16th when the CDC announced they were investigating a surge in unexplained respiratory illnesses with 94 cases in 14 states being reported. A week later public health officials announced that a patient in Illinois who was hospitalized for an unknown vaping related illness had died, and the number of cases had grown to 193 in 22 states. The week after that the number of reported cases nearly doubled to 354 cases. As of September 6th there have been over 450 cases reported to the CDC and 5 documented deaths. As of the 26th, here has been 805 cases in 48 states and 12 deaths.

So what’s going on? It’s difficult to say for certain, the investigation is still ongoing and the peer-reviewed case reports in medical journals and by state health officials don’t seem to be in complete agreement. According the New York State Department of Health, all of the 34 cases the Wadsworth center found that patients had used at least one cannabis containing product and each patient used at least one product containing Vitamin E acetate. Research published in the NEJM reported similar findings on September 6th, 83% of the 53 patients used THC-containing products. Unfortunately, it’s very hard to pin down any exact product because both reports state that patients used a variety of vaping products.

A common thread between the two reports is that both mention the brand ‘Dank Vape’ by name, and 60% of the 41 patients extensively interviewed used products with that name. There have been many people claiming that illegal or counterfeit THC-based e-liquids are to blame. I didn’t see any hard evidence for this at first but recently on the 13th there was an illegal vape cartridge operation that was busted by the cops in Wisconsin on Sunday. The searches uncovered 31,000 unfilled cartridges and 98,000 unfilled cartridges. The packaging is similar to the products public health officials in New York warned about. At this time there’s no confirmation from public health officials that this operation was responsible for the outbreak of the unknown vaping related illness, but it seems possible considering the first cases started popping up in Wisconsin and Illinois. That said, the best way to keep yourself safe from this illness is not to vape.

Banning flavors

On Wednesday September 4th, Michigan Governor Gretchen Whitmer ordered a ban on most flavored e-cigarettes. This ban should come into effect within the next for week and remain active for the next 6 months and she can reissue the ban for another 6 months. While the legislative branch could undo it, it’s probably not going to happen. As you can imagine, this was a pretty unpopular move at least in the eyes of online vaping communities and generated a fair amount of my favorite vape liquid: tears. The president of the American Vaping Association had this to say:

This shameless attempt at backdoor prohibition will close down several hundred Michigan small businesses and could send tens of thousands of ex-smokers back to deadly combustible cigarettes

Considering that 16% of high school students are using these products at least once a month, I would feel pretty shameless in my attempt to address that issue too. But will it cause thousands of ex-smokers back to regular cigarettes? I have my doubts. The ban does not apply to tobacco flavored e-cigarettes, which I assume would be acceptable to anyone who switched to e-cigarettes from tobacco cigarettes. Obviously this was a wildly unpopular move if the outrage on Twitter and Reddit is representative (it’s not), but one with legal precedent so it’s unlikely to be reversed. Will it actually combat the current trends in youth e-cigarette use? We can probably make a reasonable guess based on how the banning of flavored cigarettes affected youth smoking rates. In 2009 under the newly passed Family Smoking and Tobacco Control Act, the FDA banned cigarettes that contained flavors other than menthol and tobacco (obviously). In 2017 there was a study published in The American Journal of Preventative Medicine looking at the association between the 2009 ban and adolescent tobacco use. Banning flavored cigarette use resulted in a 17% decrease in youth cigarette smoking, in addition to a 54% decrease in the number of cigarettes smoked by youth smokers. However, it was found that youth switched to either menthol cigarettes or other flavored tobacco cigarettes such as cigars or pipes. Overall there was a 6% decrease in youth tobacco use.

It’s pretty common to hear public health officials say that companies are enticing kids with candy- and fruit- flavored nicotine products, but is there any evidence for it? In 2007, the World Health Organization put out a 117-page long report on the scientific basis of tobacco product regulation. I think their findings regarding flavored tobacco products on page 38 are pretty relevant:

  1. The tobacco industry maintains that it supports youth smoking prevention and that it has put a stop to the targeting of young smokers. However, the evidence suggests that tobacco manufacturers continue to target young and inexperienced smokers with increasingly sophisticated products and marketing, in particular with flavoured tobacco products.
  2. Youth targeting through marketing and product modifications influences youth smoking behaviour.
  3. The use of new flavour technologies raises further questions regarding the practices of the tobacco industry, particularly given the current lack of regulation

According the research the WHO cites, 20% of young smokers report using flavored cigarettes, while only 6% of smokers over the age of 25 report using flavored cigarettes. The report also raises concerns about the safety of flavorings as many are largely unregulated, which very much applies to e-cigarettes today. The report concludes by recommending that tobacco manufacturers be required to disclose flavoring agents in tobacco products, disallowing manufacturers to imply flavored cigarettes have reduced health risks, barring tobacco manufacturers from introducing new flavored products, and that states should regulate flavoring agents. Ultimately, it’s clear that flavored nicotine products in e-cigarettes encourage kids to try e-cigarette products and experiment with different flavors while getting hooked on nicotine. Regulating flavored e-cigarette products would be a good way to tackle the youth vaping epidemic and on Wednesday, President Trump announced a plan to ban the sale of non-tobacco flavored e-cigarettes.

Bad behavior

The youth vaping epidemic has been the talk of the town in schools for a while now, and there are good and bad ways to respond to that. Unfortunately many schools have taken the wrong approach, and I think it’s important to talk about it. There have been many reports of schools, installing ‘vape’ sensors in bathrooms, removing bathroom stalls, and even implementing drug tests for students to test them for nicotine if they want to participate in extracurricular activities.

First things first, I’m skeptical that ‘vape sensors’ work very well, and I believe they would lead to many false positives. Using smoke detectors as a model, most e-cigarettes will not set off smoke detectors and the sensors would have to be highly sensitive. These devices presumably work by photoelectric and/or ionization sensors. Photoelectric sensors work by shooting a beam of light across the chamber, when smoke enters the chamber it causes the light to scatter and enter another chamber that triggers the alarm. Ionization sensors work by a thin layer of radioactive particles sitting between two electric plates that causes ions to flow between them. When smoke enters, it disrupts the flow of ions and the alarm triggers. As you can imagine, photoelectric sensors would be basically worthless because the vapor from e-cigarettes isn’t as thick and dissipates very quickly, so unless the student blows directly at the device, it probably won’t trigger. It’s unlikely that ionization sensors will detect a student vaping in a timely manner, or at all, because the chemicals from the vapor would have to reach the sensor in a concentration high enough to trip the alarm.

I’ve searched for a fair amount of time, and I’ve been unable to find any good discussions about how well they work. The best endorsement I could find was from a Chicago high school administrator saying “they were starting to work after a streak of false positives”, but he really didn’t confirm that they had successfully caught students vaping in the bathroom with them. One Palo Alto high school student reported that he was interrogated by school administrators after one of the devices randomly triggered. I was unable to find any information about the detection capability of the most popular device, the Fly Sense by Soter Technologies. Performing a simple test and writing a report would be a very easy thing to do. The company that makes it was founded in 2017, and the only coverage they’ve received is by outlets that do sponsored content frequently. The only demonstrations of their device I’ve seen have been people exhaling an e-cigarette directly at the device to trigger it. In my opinion these devices are likely ineffective, a waste of money, and an invasion of student privacy.

According to a survey conducted by TruthInitiative, 9% of school administrators said they had removed stall doors in the restroom. School administrators: could you from a purely PR perspective…not do that? Bathrooms are meant to be a private place to…you know…go to the bathroom. Nine percent of students report being bullied while in the restroom, a number I can only reasonably infer would increase when you remove any amount of privacy that students have while in the bathroom. It’s a well-established scientific fact that children ages 12-16 are actually the worst, please do not give them the opportunity to lower the bar. There is no evidence that removing the bathroom stall doors discourages students from vaping in the bathroom; why would it? Anyone can smell that someone is vaping in the bathroom.

Some schools have begun requiring students to submit to random drug tests if they want to partake in extracurricular activities. So any in addition to whatever schools are already spending, it’s going to cost more. Firstly, whenever you give someone a medical test there is always the possibility you will get a false-positive result. Secondly, have been studies showing that teens that participate in school sports are less likely to smoke or drink alcohol than kids who didn’t. While correlation doesn’t necessarily imply causation, I think we can imply causation fairly comfortably in this case. Do you know what kids aren’t doing when they’re participating in school clubs and playing sports? Drinking, vaping and trying drugs.

In a similar vein, some schools are punishing students caught vaping at school by suspending them. Using marijuana as a model, there have been studies showing that students suspended for violating drug policies at school were more likely to continue to use marijuana. In a study published in The American Journal of Public Health it was found that students who attended schools with suspension policies were 1.6 times more likely to use marijuana than schools that used different policies. So what’s the better way forward here? The study also showed that schools with counseling and abstinence-based policies were associated with lower marijuana use. It seems pretty reasonable that following the researchers’ recommendations of using abstinence messages, enforcing non-use policies, and adopting a remedial approach for policy violations rather than use of suspensions is the best way to tackle the vaping problem in schools.

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Posted by Braden MacBeth

I'm a software engineer and I plan to apply to medical school next year.