I am Dr. Michael Siegel, researcher focusing on tobacco control policies & their impact on youth & adult smoking behavior. AMA about the youth vaping epidemic & respiratory disease outbreak.

It is beyond me to understand how the "vaping-crisis" is happening with about 3 dozen people dying (in total) of vaping (where they bought black-market vitamin-E laced juice) and all the while regular cigarettes are still responsible for 480,000 deaths each year. Do I have to assume that the tobacco lobbyist are fueling this fire? How can this even be a thing? Why aren't legislators just as fast and furious about tobacco-products? Besides from not smoking altogether, vaping IS the better alternative to smoking, right?

You are correct that we seem to have completely lost sight of the fact that smoking is still the #1 cause of preventable death in the United States. Frankly, we have completely abandoned smokers. No one seems to care that they continue to smoke and that they are on the road to disease and premature death. The success rate of NRT is only 10%, yet we are perfectly satisfied with that dismal percentage.

I am not satisfied. We need to have something to offer to the other 90% who are NOT going to quit using the standard "FDA-approved" methods. E-cigarettes are just that alternative! And so what are we doing? Trying to take this option away from smokers. It makes no sense.

So how can we explain this? Frankly, I think what's going on is that in 2019, the population that still smokes tends to be people with less political power - lower socioeconomic status individuals. They have been stigmatized and are viewed as having a moral failure, not just a health problem. We don't treat people with other vices this way because those vices (like drinking and smoking pot) affect upper socioeconomic classes as well.

The bottom line is that because of their social class and lack of political power, smokers have been thrown under the bus. And because politicians can now get an easy political victory from banning e-cigarette flavors, they are jumping on the bandwagon to do this regardless of the terrible effects of such a policy for smokers and ex-smokers.

Hello Dr. Siegel, I'm 33 years old and quit a 10 year smoking habit about 6 years ago. I'm worried that if I can no longer get my vape supplies and run out, the temptation to buy a pack of smokes will overcome me and I will return to smoking cigarettes. I feel my only alternative options would to be to seek out ejuice on the black market or possibly try snus to see if that helps. What do I do?

Your situation is exactly why I (and many others) are fighting so hard to try to keep e-cigarettes on the market rather than to have them banned. This is not a decision that you should have to make. You've succeeded using e-cigarettes and there is no reason why they should be taken off the market and you should have to look for an alternative option, such as the black market, in order to avoid going back to smoking. Let's hope it doesn't come to that.

Just wanted to find a comment like this: I personally have a condition known as hypofrontality where the only proven “cure” is nicotine in which if I can no longer buy supplies to make juice or just buy juice I will be back on cigarettes the same day my juice supply runs out because ADHD-like symptoms and general fogginess and short-term memory issues start to happen due to the ADHD ability of paying attention.

Is it your belief that either big tobacco, big pharma, or perhaps both are a big cause behind these recent attempts at banning? Every time some mythology of vaping pops up in the news it dies down shortly after and everyone leaves it alone. Now nobody leaves it alone(I get stopped on the streets now by strangers telling me that people are dying from vaping) and the recent media is constantly making it worse. Were Pod-systems like JUUL to makes vaping discrete and easy to do literally anywhere a huge factor that the government was looking for to finally slam the final nail in the coffin?

Thank you for your time. :’)

Sadly, I don't think the tobacco companies are behind this because I think health officials and anti-tobacco groups are doing the work for them. They can just sit back and watch the anti-tobacco movement help destroy the main competition to cigarettes, secure cigarette consumption for the future, and bolster the value of tobacco stocks for a long time to come. That's what makes this so sad. If the tobacco companies were behind it, I could understand. But it is sad that it is the anti-tobacco groups that are doing all the dirty work for the cigarette companies.

Hi Everyone! Thanks for joining me!

I want to start with two overall comments:

1. First, I want to thank all the vapers out there for your support. It means a lot to me. As you know, I think that quitting smoking is one of the most difficult things to do and I congratulate and admire the 2.5 million vapers who have successfully quit smoking by switching to electronic cigarettes. And many of you have shared your experiences with others by going into the business of trying to make the same thing possible for thousands of others. I admire and applaud you!

2. Second, I think the primary purpose of any outbreak investigation should be, first, to prevent future cases. I don't think that the CDC has done a good job in this area because they have been so obsessed with the idea of finding a single product to explain the outbreak that they have lost sight of the overall purpose of the investigation. No outbreak investigation ever finds 100% of the cases share a common exposure. The fact is that 90% of the cases appear to be linked to THC vaping. The priority now should be to warn the public, especially youth, to avoid vaping THC. This should not be undermined by telling people: "However, not every case has reported exposure to a single product." We know enough right now to curtail this outbreak. But we are not communicating the right message.

What can we, the public, do to get those flavor bans revoked?

I think vapers need to contact their legislators and share their experiences. There are millions out there. That is a lot of voices.

Just in case you're still here :) What are your top five bullet points for legislators on the Youth vaping epidemic.

Mine would be

• Limit Nicotine to 20 Mg in *normal commerce. (JUUL is incredibly effective for immediate switch from cigs, so need options for current smokers to access these without undue burdon like Prescription)
• Limit Vaping (And all tobacco fercripessakes but that won't fly) to 21+ vape shops/tobacconists
• Tobacco 21 Federally (If Reagan could do it for alcohol, who's the opposition?)
• Encourage law enforcement get friendly with any retailer where tobacco products are sold
• Age verification technology on all internet orders. (Not everyone has a local vape shop)

I agree with all five of your recommendations.

In addition, I would add strict regulation by the FDA, with safety standards, not pre-market tobacco applications that are going to result in the closure of most vape shops.

The PMTA guidelines are the real grim reaper waiting to kill vaping. Stopping flavor bans is important, but that effort will be wasted if people don't start addressing PMTA guidelines. How do you think PMTA will ultimately affect the vaping market?

The PMTA requirement is going to devastate the vaping market, basically handing it over to the tobacco companies and perhaps a small number of the largest independent e-cigarette companies. There will be a huge contraction of the market and almost all products will be sold only in the largest retail chains, wiping out most vape shops. The overall vaping market will plateau and then decline substantially. And finally, a new black market for e-liquids will develop and there will be a huge increase in DIY vaping.

Hello! As a child a lot of my family were smokers, of cigarettes, but as I’m now a student in college I feel that I barely see anyone choosing cigarettes as their smoke of choice. Have you seen any correlation between growing up in a household that smokes and choosing to vape/smoke week? Also are cigarettes just a dying breed?

There's no question that growing up in a home where someone smokes increases the chances that a youth will also smoke or use other tobacco products or vape. You are right that the culture of smoking is gradually dissipating, but it is largely being replaced by a culture of vaping. I do think that cigarettes are a gradually dying breed; however, there are still 35 million smokers and there are going to be tens of millions of premature deaths in the coming years because of that. We need to do something for these 35 million smokers to help them get off deadly cigarettes.

it is largely being replaced by a culture of vaping

and its happened quickly in just the last few years, same with something like the smart cell phone or streaming on smart TVs - but is it a bad "epidemic" or should it even be called an "epidemic" at all if its a smarter move ... maybe smart-cigarette use instead?

yes it is happening the quickest with younger adults that embrace change more readily ...as I've thoroughly combed thru the NYTS and MTF data and seen where while underage have tried it(reporting their use as mostly 1-2 times a month, and 1-10 times in their whole life) it appears that full time college male students of legal age are the biggest group of new vapers showing the fastest uptake - using vaping more steadily than underage - do we have concern for this group if they are prodomitaly not picking smoking of tradisional tobacco cigarettes as much as the same age group who are not enrolled in full time college? as I never see any focus in media or by agences that has an issue with them, where I feel this is when people develop and secure their lifelong habits, even tho most smokers(now vapers?) might have tried it in high school, they don't all become dependant until college years - what are your feelings of this group(males in college) if they are also the most influential to the future of smoking/vaping and also to the other age groups around them that might be lead by their change?

You make a critical point. While there is a lot of attention focused on youth (middle- and high-school), college-age young adults have fallen off the radar screen. Not only are e-cigarettes popular among college students, but so is marijuana, including vaping of marijuana. In fact, it appears that the college-age group is the most affected by the outbreak, probably because the use of black market THC vape carts is highest among this group. National data show that marijuana use among college-age youth has reached a 35-year high. Nearly half of college students report having used marijuana recently. A large proportion of those are vaping THC.

THANKS EVERYONE for your participation and your thoughtful questions!

I am signing off now, but will return tonight and try to answer any remaining questions.

I was a 20 yr smoker. Gave up with ecig, been vaping 10 years now. I use very low nic, 3mg, and the flavors of being NOT close to tobacco helped me quit. I don't think people in charge like the fact we got off cigs without using massively expensive Pharma products (which are proven to not work long term in the majority of cases).

My question; do they realize, or indeed care, that they are going to spark a huge blackmarket/underground market in flavors and nic lquid. There will be no tax paid as there is now, and less QA than there is now which will likely result in even MORE health problems. Also banning things never stopped kids from getting to them (like alcohol or weed).

I agree with you completely. No - I don't think they have thought about the implications of their policy. Frankly, I don't think they know enough about the vaping market to make informed policy decisions. The result is most definitely going to be a huge black market in flavors and e-liquids. I don't think they realize how easy it is to DIY these products. I also don't think they have a clue about how youth are obtaining vaping products and they mistakenly believe it's all about attractive flavors. It's not. It's about getting a high without putting your life at risk from smoking. And it's about the products that are being distributed by the students who are the main dealers. Everyone in a school knows who those kids are. The kids are going to vape whatever those few students are distributing. So if it isn't flavored e-liquids, it is most likely going to be THC vape carts, as they will remain easily accessible to youth. The result of all of this is going to be MORE health problems, not less, just as you say.

It is refreshing to see a credible professional, such as yourself, dispelling all the myths currently floating around. I am one of the many who switched from cigarettes to vaping and slowly reduced my nicotine intake to the lowest concentration vape juice available.

Would you say your views are shared widely among the medical community? Or are you a lone voice fighting the current hysteria?

I'm not a lone voice. There are others with similar views. But we are definitely in the minority.

Good afternoon, Dr. Siegel. I greatly appreciate all of your efforts more than you know.

Is there a predetermined percentage of the population that allows someone to start ringing the "epidemic" bell?

There is no clear definition of a percentage of people who have to be affected before it can be called an "epidemic." This is a completely subjective term. For example, why do we say that youth vaping is an "epidemic" but youth alcohol use is not? These are socially constructed terms that are more reflective of the way that society views an issue rather than some sort of objective epidemiological criteria.

Wow. Everything you've already stated really sums up my understanding of the situation. It is black market products and knockoffs that are the main issue, correct? As a person in a non-medical/non-recreational state, I have reverted to smoking marijuana flower instead of vaping products. Would you say that places like Michigan overreacting will cause more harm to public health than it will help? Where do you get your information?

I think the overreactions are problematic. Perhaps it's not so much of an overreaction as it is conflating the outbreak with the youth vaping problem. These flavored e-cigarette bans are going to have 3 adverse effects:

1. They are going to force many ex-smokers to return to smoking.
2. Most of the ex-smokers who don't return to smoking are going to start buying products on the black market.
3. It is going to cause a transition in the e-liquids that you are vaping - away from flavored nicotine-containing products and toward THC products, which remain easily available off the internet or off the street.

All three of these effects will have severe adverse consequences for the public's health.

Note that #1 and #2 above are not just speculation. We now have actual sales data from Massachusetts which documents that there has been a substantial increase in smoking during the 4 weeks that the vaping product sales ban has been in effect. In addition, we have survey data showing that a substantial number of people who vape have switched over to black market products.

How do you feel about legalization and regulation of THC products? Do you believe this would also be a step in the right direction to keep public health risks to a minimum?

I think that at this point, the cat is out of the bag. A huge underground THC market has developed. So at this point, I think that cannabis has to be de-classified as a controlled substance by the federal government so that these products can be regulated in all 50 states and so that the federal government also has some jurisdiction over the safety of these products. So yes, legalization and regulation of THC products would be a step in the right direction.

Hi Dr. Siegel, Thank you for being a true example of a knowledgeable and compassionate public health advocate and especially with your help in disseminating the facts and fiction in regards to vaping. I'm in Massachusetts and I am extremely concerned with what is occurring here on a public health standpoint and given the info we do know that the cases are linked to illicit THC, why are they still claiming to not know the cause and reporting the two deaths as solely nicotine related?

I can't speak to the two deaths that were reported as "nicotine-related" because I simply don't have access to detailed information about those cases. However, keep in mind that earlier in the outbreak, Massachusetts DPH had data showing that 9 out of the first 10 confirmed cases had vaped THC. Armed with that information, they immediately banned the sale of ALL vaping products and did nothing to alert the public to the risks of vaping cannabis. I think that there is some sort of underlying bias against e-cigarettes going on and health agencies are using the opportunity of the outbreak to further demonize e-cigarettes. This is unfortunate because it is leading to bad public policy decisions.

How long are we going to allow politicians to use the plausible deniability defense as they ignore advocates like you and the mountain of evidence in favor of your position as they continue to erode the vapor industry?

I don't think we should allow it at all. There should be a loud outcry from people who have saved their lives by switching to vaping.

And I do think that the voices of vapers do make a difference. The ONLY reason why I think there is even a slight chance that the FDA might not ban e-cigarette flavors completely is that some advisors have convinced President Trump that alienating the vaping community might affect his chances for re-election. THAT is the angle that has the best chance to de-rail a potential flavor ban. So vapers need to continue to make their voices heard, especially to the administration.

The CDC is getting funding (or rather it's budget) is determined by congress and are beneficiaries of the MSA agreement etc.. given the track record of previous FDA heads and links to big pharm etc both post and prior to their post, :

do you believe the CDC is compromised to some degree?

(respectfully) as they seem real slow to give proper information and as you said 90% fall into a particular subset which aren't as attractive to news agencies or seem to push forward the agenda of some big money lobbies...

(and thank you and all respect for your work)

I don't think it is a result of compromise because of financial incentives; I think it is more of an ideological bias against smokers and against the idea that someone could be addicted to nicotine yet derive pleasure from it. We accept that concept for alcohol. We accept that concept for cannabis. We accept that concept for poor diets and lack of physical activity. But we don't accept it for smoking. Ultimately, that is what I think is clouding the CDC's response.

against the idea that someone could be addicted to nicotine yet derive pleasure from it

Do you mean:

against the idea that someone could not be addicted to nicotine yet derive pleasure from it

I am fully open to being wrong here and if I am I would like to know why because it confuses me and I might need some extra context.

Sorry I wasn't clear. What I meant to say was that the anti-tobacco groups simply cannot tolerate the idea that someone could be using nicotine but not suffering health effects. In other words, they can't tolerate the idea that someone could be using nicotine AND improving their health.

Their thinking is black-and-white. Nicotine is either all-good or all-bad. There is no middle ground. So if you're using nicotine, it is bad. Period.

Hi Professor! I took your class on public health advocacy a year ago (spring 2018) and it was one of my favorite classes I took in school. I would love to hear more on what you think the best approach is for regulating vaping products - as there is a benefit vis a vis weaning smokers off of cigarettes - while still preventing youth risks (especially considering youth vaping, nicotine or otherwise, can change a teen's perspective on tobacco products). I recently wrote an article about this for work but would love to hear more about what you think should be done in this area? What is the best way to address regulation that doesn't prevent those who actually benefit from vaping products to have access?

Thanks for that great question.

I think that there is too much polarization around the issue of e-cigarettes. This is not an ALL or NOTHING scenario. The choices are not simply to let the free market reign or to ban the product completely. But that seems to be the only options that are being considered.

I think that we can balance competing objectives. That is what public health is all about. We can find a way to keep e-cigarettes on the market for adults, while minimizing the risks to youth. Here are some preliminary ideas of how I think this could be done:

1. Ban the sale of all tobacco products, including both e-cigarettes and real cigarettes, to stores that are only open to people 21 years and older and which only sell either just e-cigarettes (vape shops) or just e-cigarettes and tobacco products). Just like most states do for alcohol. You can't walk into a Cumberland Farms store and buy a bottle of vodka. There's no reason why in 2019, a youth should be able to walk into a convenience store and buy a deadly cigarette or a vaping product.
2. Restrict the level of nicotine in e-liquids. You don't need 54 mg/mL of nicotine in an e-liquid for smokers to succeed in using the product to quit smoking. In the UK, they have a limit of 20 mg/mL and data show that it is extremely effective in helping smokers quit. I think this would help minimize youth addiction to vaping, which I see as the main problem. Short term use of cherry vape is not going to kill anyone.
3. Regulate the safety of the product. The FDA should issue safety standards for e-cigarettes. This direct approach makes more sense than the current prohibitionist approach which is going to decimate 99% of the e-cigarette market by requiring expensive applications that only the tobacco companies can afford.

Thank you for this! I was also wondering - how do you think we can educate youth on current vaping dangers before these regulations are put in place? I've talked to people with high-school aged siblings, and they've said they've seen their siblings and their friends go through a single Juul pod a day without thinking anything of it. What is the best way to alert youth to this fact while waiting for regulatory action to take place?

I think the best way is to educate youth about the high addiction potential of JUUL. Kids hate to be controlled or not to be independent, so stressing that the product is designed in a way to maximize addiction can be an effective way of taking the glamour out of using the product. This is what worked with reducing smoking, so I think it could work with vaping as well.

Do you think Gov. Baker's temp ban will lead to a permanent ban, or restrictive legislature (ie no flavors) for MA?

I suspect that the legislature is probably going to enact a ban on all flavored e-cigarettes. If that happens, then there will not be a need for the administration to extend the ban. I think the state is going to turn to the legislative route from this point forward. I expect a flavor ban to be passed in the current legislative session (which extends into 2020).

Wow! I was honestly coming here expecting to see the typical anti-smoking propaganda. It was refreshing to see someone speaking to the dangers of tobacco with integrity.

Quick question, chewing is obviously a horribly unhealthy habit but, how bad is compared to smoking?

Chewing tobacco is unhealthy - it is a risk factor for oral cancer, gum disease, tooth loss, and possibly with cardiovascular disease. However, it is not as dangerous as smoking in the sense that the absolute risk of product-associated disease and death is lower. Nevertheless, with the availability of snus (which is significantly safer than smoking), I would never recommend the use of smokeless tobacco for harm reduction for smokers.

Do you notice any sort of similarities or common traits in the people who strongly oppose vaping (in either a legal or interpersonal way)?

I, too, have successfully quit cigarettes through vaping. I feel a world of difference for it, and I was only smoking them for two years tops.

Yes - they tend to be more liberal and are more likely to be Democrats. When I was testifying before Congress, support for the flavor ban was essentially split along party lines, with Democrats supporting it and Republicans against it. The Democratic Congressmembers were grilling me (and one was insulting me), while the Republicans were throwing me softballs. It is a very strange (and ironic) juxtaposition of interests, but for whatever reason, that is the reality we are dealing with.

Hello there Doc!
What made you want to become an advocate for vaping?

Have any lobbyists or predominant anti-vaping zealots ever approached you and asked you to stop supporting the industry?

Thank you for all that you do and that you continue to do.

When e-cigarettes first came on the market, I thought it was just another tobacco industry ploy to market a product as being safer than smoking just to recruit more customers. But I spent a year educating myself about the industry. I studied the products. I spoke with hundreds of vapers. It became clear that this was something totally different. It had nothing to do with the tobacco companies (they were not involved until 2011). These products were indeed safer and many smokers were using them successfully to quit smoking.

So it's the actual data - the hard evidence - that changed my opinion.

I think that I started out in the same place as most anti-tobacco advocates today. It's just that my thinking evolved as the scientific data and information came out, while most of the anti-tobacco groups just made up their minds at the beginning that they were against these products and have never even considered altering their stance.

Hey /u/mbsiegel ! What is the general consensus around vaping in the medical community? It seems split right down the middle, but if you look at the data, it's clear that vaping is far safer.

There is no question that e-cigarette vaping is far safer than smoking. Unfortunately, I don't think the medical community is spread down the middle. I think it is more like 90% do not embrace vaping as a legitimate harm reduction approach and 10% do. It's certainly true that among health organizations, this is the case. I'm not aware of surveys of individual physicians, but I suspect that their opinions largely mirror that of these organizations.

Hi Dr. Siegel,

From the cannabis side of things, to the best of my understanding most of the issues arising come from vaping thc cartridges filled with distillate, terpenes, and various thickening agents, yet experts (yourself included) have linked the sickness to vaping thc. Does evidence suggest that this is truly related to vaping thc in all forms? For example, is it still safe (well...relatively, I won't contend that pot is good for most recreational users) to vape flower? What about vaping various forms of pure concentrate such as wax or shatter in a handheld device, that don't include any additives and are in theory tested to ensure they've been purged of all solvents?

Thanks for your response.

To be clear, it is not the THC itself that is being implicated here. It is the distilling agents - either cutting agents or thickening agents - that are most likely the source if the problem. So vaping cannabis flower or pure distillate does not appear to be associated with this outbreak.

As someone who quit smoking with a Juul I was wondering if there was research on the long term side effects of nicotine use? Also how do you think all these bans, which to me are easy political points because no one wants kids smoking, are going to effect people who vape nicotine? Lastly, what do you think about the hypocrisy of the argument that nicotine/vapes advertise to children/ are dangerous, when alcohol is a known carcinogen that in any amount is a carcinogen? I feel like alcohol is a greater threat to the pop. Than nicotine, but it’s abuses are ignored because most people do drink.

We don't know a lot about the long-term effects of nicotine alone because it has always been studied as one component of a product (tobacco). However, I think it's safe to say that MOST of the health effects of smoking are attributable to the tar, rather than the nicotine alone. What it's safe to say is that regardless of any potential long-term effects of nicotine use, vaping is much, much safer than smoking.

The effect that these bans are going to have on people who vape nicotine is:

(1) Many will turn back to smoking if their products are taken off the market;

(2) Most of those who don't return to smoking will go to the black market to obtain their products. If this outbreak teaches us anything, it is the dangers of having products sold on the black market rather than in a regulated market.

Finally, I agree with your observations about the way health agencies are treating alcohol compared to nicotine. See my response below about flavored alcoholic beverages.

Hi Dr. Siegel! What happened to Ned Sharpless? Matt from SMM just said that he’s no longer acting FDA commissioner.

Hello Dr. Siegel, it is my understanding that public health England is pro vaping as a harm.reduction tool for smokers trying to quit. Are they not facing losing money from cigarette sales like we are here in the US? No MSA money or UK equivalent of it? Or is it because the cost of smoking related illnesses outway any money they get from cigarette sales?

You're exactly right. In the UK, the National Health Service has embraced harm reduction in tobacco control and they have officially approved electronic cigarettes for use in smoking cessation. Since they have universal health care, the government is paying for medical care for all smoking-related illnesses. So the more people who switching to e-cigarettes, the lower the government's health care costs. This is almost certainly outweighing revenues they get from cigarette taxes.

You are absolutely correct fleetpqw24.

The Trump administration has removed Dr. Ned Sharpless as FDA commissioner effective immediately.

The reason for this is pretty clear: the voices of vapers have been heard! Trump's advisors told him that the proposed flavor ban was alienating many vapers and could affect his re-election chances. It is likely that Sharpless refused to weaken the ban so had to go. Now, it appears that at very least, mint and menthol-flavored products will still be allowed.

This is completely due to the voices of the vaping community!

I wasn't aware of that. Will check and see if I can find out more.

How has the CDC not found the root cause yet, it's been what 4 months? Seems like they are taking their time in efforts to destroy the vaping industry. I live in Mass and the only reason why the ban still is in place is because of the CDC not confirming what exactly is killing people.

I think one of the reasons it is taking so long is that they want to try to leave open the possibility that nicotine-containing e-cigarettes are implicated in the outbreak. One of the principles of outbreak investigation (or any investigation) is that when you get a lead, you aggressively pursue that lead. The CDC got a great lead - vitamin E acetate was found in THC cartridges of EVERY CASE PATIENT in New York State who reported using THC. But instead of aggressively pursuing that lead, they undermined it by continuing to implicate traditional e-cigarettes.

In contrast, Leafly aggressively pursued that very same lead and they were able to essentially piece together the whole puzzle. They were able to follow the supply chain all the way back to factories in China and to a section of LA that is packed with black market THC oil wholesale distributors.

Frankly, I think that Leafly has done a better job of doing this investigation and has contributed more to our understanding of it than the CDC.

Why is this crisis being confused with nicotine vaping? I understand the concern about getting vapes out of the hands of kids but not getting the THC information for front has literally cost lives.

Unfortunately, I think it is intentional. I think that politicians and health organizations have seized upon this outbreak as an opportunity to promote their agenda of getting rid of e-cigarettes, or at least non-tobacco-flavored e-cigarettes. This is why they are not communicating the facts about this outbreak accurately. (There are exceptions - I think the Utah Department of Health is an example of an agency whose communications have been appropriate).

Again, I think the confusion that agencies like the CDC has created is intentional. They WANT to be able to include e-cigarettes in this outbreak, regardless of what the data actually show.

Even the name they gave to the outbreak is intentionally crafted to implicate e-cigarettes in the crisis. That's why they are calling this the e-cigarette, or vaping-related lung illness. From the data we have right now, this is probably inaccurate. It's not an e-cigarette-related outbreak, it's a THC and black market vaping-associated outbreak.

I'm almost a 60 year old woman and i get another chance because of your work and advocacy and the work of others like you. My husband quit with me. I smoked 36 years and vaped 2, these days I vape the occasional 0mg when I miss it (which isn't often). Thank you sir for all you do. I don't really vape anymore but this scares the hell out of me for the sake of my husband and daughter who still vape.
Heartfelt thank you. We will be in DC on the 9th

Congratulations to you for quitting smoking! Thanks for your kind words, and I will continue fighting against these poor public policies so that your husband and daughter will not have to choose between turning to the black market or going back to smoking.

I think this is intentional. I think it is an opportunity to advance a pre-ordained agenda of wiping out the e-cigarette market by using the outbreak as a justification for banning these products.

How a ban on flavors would have serious and immediate adverse effects on the U.S. and state economies

I'm not particularly well-versed on the subject, from what I understand, flavor bans were generally targeted at flavors such as bubblegum or cotton candy which are targeted towards younger users. In my limited knowledge, I understand that selling less would have adverse effects on economies, but wouldn't the public health benefits outweigh this?

The first thing to understand is that there is NO SUCH THING as an unflavored e-cigarette. EVERY e-cigarette has a flavor. The question is simply what flavor. The ingredients of virtually all e-cigarettes are: propylene glycol, glycerin, water, nicotine, and flavorings. So every e-liquid is flavored.

When public health officials talk about banning "flavored e-cigarettes," what they really mean is that they are banning every single flavor OTHER THAN tobacco-flavor.

Because the tobacco flavor is only one of hundreds (if not thousands), if you eliminate all of the flavors except tobacco, you are basically taking e-cigarettes out of the hands of millions of vapers. Such a policy will result in the closure of most small vape shops. Or it will force vape shops to start selling real cigarettes instead of fake ones.

It's not clear how much public health benefit there would be to banning e-cigarette flavors. It is likely that a black market will develop and so youth will likely just get their products off the black market instead of from stores. I don't see how that helps the situation. But it could make it a lot worse.

Hi Dr Siegel, my dear is that vapers are going to be treated with the same tone deaf dismissal as smokers. I have a feeling that a lot of the anti vaping noise has been sparked by the sharp decline in tax revenue as more and more people give up the smokes, such as myself. I see this as a way to hand the entire industry right back to big tobacco so that it can be controlled and taxed, but it won't be vaping anymore. What are your thoughts on this, and how can we leverage ourselves better when we are being robbed of a place at the table for discussion? We need more medical professionals speaking out like you are.

I agree with you - the direction we are going now is head-first into handing the entire industry to the tobacco companies. In my opinion, it is the fact that there are so many small businesses (vape shops) involved in the e-cigarette market that has made this market so effective in helping smokers quit. If the market is handed to the tobacco companies, there will be a huge contraction of the market, demand will drop, and there will be many fewer products available. Vape shops will go out of business and all of the sales will take place at convenience stores and other stores with which tobacco companies have had retailing relationships for many years.

In fact, tobacco economic analysts are predicting that a flavor ban is going to increase cigarette consumption by driving many ex-smoking vapers back to smoking. They are rating tobacco stocks as a "Strong Buy" for that reason, and because those are the companies best positioned to be able to withstand the PMTA process and a partial flavor ban.

I think the vaping community is doing a great job of making their voices heard, but what we need are more medical professionals speaking out, just as you suggest.

It seems the flavor ban lobbying is driven by Bloomberg and CfTfK mostly. And the Campaign has a cozy history with menthol cigarettes. So I'd assume they're likely targeting the fancy/pricey adult flavors. But menthol/mint will be left untouched - even if teenagers use such pods predominantly.

So, would you think the tobacco control lobbying groups are genuinely trying to reduce teen use? (Given the focus on the cotton candy strawman, but not nicotine concentration or composition.)

I don't think there's anything insincere about the intentions of these groups. I think they are sincere in wanting to reduce teen vaping. However, you can't just look at one side of the issue. You have to consider all the effects of a public health policy. And banning flavors will lead to disastrous consequences for millions of adult smokers and ex-smokers.

So the real question is why aren't the tobacco control groups giving any weight to the effects on adult smokers. Frankly, I really don't think they sincerely care about smokers. I hate to have to say this, but I think that smoking has become "moralized" in public health. It is not viewed purely as a health issue, but as a moral issue. Smokers are making bad decisions. They are "addicts." And it is OK if they get "punished" for these bad decisions.

The CDC actually stated directly (explicitly) that they were only concerned about youth vaping and were willing to throw smokers completely under the bus.

So they are not being insincere about their intentions. It's just that their intentions themselves are misplaced.

Hi! Thank you for giving us a chance to be heard! I quit cigarettes and have been using vaping as a nictoine replacement and a tool to completely taper off of nictoine, I was at 12mg and now I am at 3mg, it works! And I have not been miserable during the process, vaping is definitely the best way to quit.

Forgive me for the huge amount of text below, I'll understand if you choose to skip to a shorter question/response haha.

QUESTION: I want to ask you why the news sources and politicians haven't really seemed to separate the issue with illicit THC products from normal and safe nictoine vaping products. It seems that almost every article I read leaves out so many details about the whole problem and suspiciously chooses to publish only what supports this whole fearmongering craze. I feel like there is information that isn't being shared

And I understand that youth vaping is a problem, but a ban won't help anything, kids have always found ways to get their hands on cigarettes, vapes, alcohol, marijuana, and any other drug or substance they want. There may be a solution to youth vaping, but bans will not solve anything, it will drive more kids to buy products from untrustworthy, shady sources/people/etc., which will create a much bigger problem. I'm baffled that so many politicians and reporters/writers (so I've seen on the internet) don't mention anything about the future problems these bans will cause. And some seem to all be on page 1, claiming "vaping kills" and sharing no information at all.

And also, I'm interested in in what you think we should do to possibly help reverse the damage done to the image of vaping, and reverse the negative stigma that has been surrounding it, so that we can keep it around for us quitters. We've all signed petitions and called the white house, I feel like there must be something else we can do to show people the real problem, educate people about these unregulated and unsafe THC cartrages being sold, and show that normal nictoine vaping products from reputable companies being used by adults who are trying to quit cigarettes is a positive thing. What can we do to help?

Thanks for this thoughtful analysis and great questions.

First, the reason why health officials haven't really seemed to separate the issue with illicit THC products from normal and safe nicotine vaping products is that THEY DON'T WANT TO. In other words, I think it is intentional, not some sort of oversight or failure of communication. I honestly think they are communicating exactly what they are trying to. They are trying to confuse people because they don't want to give up on the idea that traditional e-cigarettes - the kind you buy at stores - are extremely dangerous. I think they are actually hoping that is the case and they are sticking to that story no matter how much data comes in showing that tainted black market THC vape carts are the real problem.

Second, I agree with you that simply banning flavored e-liquids is not necessarily going to solve the problem of youth vaping. If these youth simply wanted good flavors, they could go out and buy ice cream or jelly beans. The reason why they are Juuling and using vape pens is because it's a discreet way to experience a high and it is cool and doesn't put your health at risk like smoking does (they're not connecting THC vaping with the outbreak because health officials are telling them that "e-cigarettes" are the problem). What is going to happen is that there will be a shift in the types of products that kids vape and that is going to transition them more towards the THC products, which will remain readily available. Ironically, the bans will do NOTHING to curtail the outbreak but may make it substantially WORSE.

Finally, I think the vaping community is doing everything it can and simply needs to keep doing what it's doing and not give up and not go away. I think their work IS having an impact. For example, I am quite sure that it was the loud voices of vapers that caused President Trump to backtrack on the flavor ban and decide to allow mint and menthol e-liquids to remain on the market (this is the policy that I expect the FDA to announce next week).

The FDA is going to try to implement this partial flavor ban by issuing a guidance, rather than a formal rule-making process. This is going to be challenged in court by the vaping industry because the guidance process is not supposed to be used to promulgate regulations without having to go through a formal rule-making process. IF this lawsuit is successful, then it will allow more time for vapers to continue to make their voices heard, and by the time a rule-making process occurs, it may be possible to convince the agency that it makes no sense to ban the flavors.

Bottom line: Keep doing what you're doing. Make your voices heard. Don't let up . Don't give up. It doesn't look good now, but there are potential avenues that exist to block this.

Hi Dr. Siegel, I am also a physician and a public health researcher that is interested in e-cigarettes. What do you think about the "gateway theory" that e-cigarettes lead adolescents to advance to conventional cigarettes? There has been A TON OF research for that specific question and I see the general consensus is in agreement with it, which directly/indirectly will support more strict e-cigarette policies. This is such an interesting AMA! Thanks :)

Thanks for joining in and for your important question.

The basis for health advocates/researchers to claim that e-cigarettes are a gateway to smoking is research showing that youth who EXPERIMENT WITH e-cigarettes are more likely to then EXPERIMENT WITH cigarettes. The baseline variable in these studies is typically EVER use of e-cigarettes and the outcome variable is typically EVER use of cigarettes.

The REAL question, however, is whether nonsmoking youth who try e-cigarettes go on to become regular vapers (become addicted to nicotine) and THEN transition to smoking. All of the data I have seen indicates that this phenomenon is simply not occurring. There are very few nonsmoking youth who become regular vapers in the first place. Those who do are mostly using JUUL, and there is no evidence that youth who JUUL go on to become smokers. The youth who I have worked with who Juul despise cigarettes and wouldn't think of smoking. And why would a youth transition from a flavored product to a harsh, tobacco cigarette?

The truth is that a culture of vaping is REPLACING a culture of smoking, not helping to REVIVE a culture of smoking.

Other than social pressure, what's leading young people to vape? Does depression/anxiety have anything to do with it?

YES! Thank you for bringing this up. This is a point that so many of my tobacco control colleagues do not seem to understand. They think that youth are vaping because there are cool flavors. That is so naive and simplistic. If it were just about the flavors, kids could just go out and eat ice cream or jelly beans. They are vaping because they do have depression and anxiety and the use of drugs like nicotine and THC can help alleviate that, at least for a while. They are vaping because they are traumatized by school shootings and they are worried about what their world is going to look like with all the consequences of climate change. Getting rid of cherry vapes is simply not going to put an end to youth vaping. I think it's terribly naive to think that this is merely a problem because vapes come in different flavors. Ten years ago, youth dealt with anxiety and depression by smoking, yet there were no flavors. There were no cherry or bubble gum cigarettes. But kids still smoked!

Let's face it. Kids are going to use some substances. Our goal should not be abstinence because it's not going to happen. Not in this world. So what we need to do is steer them towards the safest methods of coping as possible. Having a kid use a cherry vape is not the worst thing in the world. But having them addicted to JUUL is unacceptable. If we put more attention into regulating vaping products (for example, limiting the nicotine level would have prevented the JUUL problem) rather than banning them, then we might actually help protect the health of our youth.

This has probably been asked before but do you support a universal vape ban? Not just on flavors but on all product Edit: Just for clarification I don’t support a ban but I was curious what a medical excerpt thought about it.

No - I do not support a complete ban on the sale of vaping products because I think it would force many ex-smokers back to smoking and it would create an unregulated black market that could be extremely dangerous.

How much are you getting paid by the tobacco company’s for this ? No where headlines the fact people are dying (a tiny amount may I add) from bootleg THC cartridges

I'm not getting paid by any tobacco company. But I don't understand what you mean by "No where headlines the fact people are dying from bootleg THC cartridges." Would love to hear more about what you are getting at here and I will respond.

Dr. Siegel, Do you have any expectation about when or if there will be controls on nicotine concentrate used for mixing?

Honestly, the direction the FDA is going is not a direction of regulation. It is a direction of prohibition (at least of 99% of the market). They have shown no indication that they are interested in actually regulating these products rather than simply putting most of the vape shops out of business. So I don't expect controls on nicotine concentrates any time soon.

Even though it is this type of regulation that I think is the best way to handle the problem. Strict safety regulations and restriction of nicotine levels, not just banning 99% of the products outright.

Why isn't there a single photo, or video of the "youth vaping epidemic"? I drive past two high schools fairly often near the end of my day, and visit shopping malls, and I have never seen 1/4 (or whatever they claim) of young people vaping. Wouldn't the Food Court be all cloudy?

The only pictures or media I ever see of youth vaping are the ads run by FDA and Campaign for Tobacco Free Kids.

This is because they are only presenting part of the data. While the data show that about 28% of youth have used an e-cigarette in the past 30 days, they are not telling you that most of these youth are not regular vapers - meaning that they are not vaping on most days. In addition, they are not telling you that less than 1% of youth are tobacco-naive, regular vapers. In other words, there are still not a lot of youth who are never smokers and never users of other tobacco products who take up vaping and end up vaping regularly. This is likely why the statistics that are being given out don't seem to match with your personal experience.

Thank you doctor, as you said : "The ingredients of virtually all e-cigarettes are: propylene glycol, glycerin, water, nicotine, and flavorings. So every e-liquid is flavored.",

what is it that the bans that are plaguing many states or municipalities don't understand? as synthetic strawberry is as synthetic as tobacco flavors. I see no difference myself, and if they were to say, ban flavored alcohol like peppermint schnapps or wine coolers ("for the kids" as analogous argument to their gateway problems), perhaps it would be consistent. I just don't remember hearing the alarm bells over Mike's Hard Lemonade you know?

My father is Mayo Clinic surgeon, and even he is confused and sending the trope concerned emails we all are getting..

without being "tin foil hat", does it not seem that agenda's corresponding to release of, say the IQOS, that the conflation of problems seem to be a little too convenient, or is in your opinion, this just the modern press going for low lying fruit in click bait?

You make two very insightful points.

First, no one seems to care that youth are being enticed to hard liquor use through the marketing of flavored alcoholic beverages. There is actually a reasonably strong justification for banning the sale of alcopops - flavored alcoholic beverages, as these drinks truly are a gateway to heavier alcohol use for underage youths. So we tolerate flavored alcohol but at the first sign that any youth has used a cherry vape we need to ban all flavors. This is terribly inconsistent. I think society chooses which vices are OK and which are not, and we have apparently decided that alcohol use is acceptable - nicotine use is not.

Second, the conflation of youth vaping and the outbreak is "convenient" and groups are taking advantage of it. I think it is intentional. I think they are using the outbreak as an excuse to get their anti-e-cigarette agenda in place, even though it is under false pretenses.

In fact, this is exactly what I think is happening in MA, RI, NY, MI, MT, OR, and WA with their flavored vaping product bans. They are using the outbreak as an excuse/opportunity to avoid the legislative process to get these bans in effect. I view this is a violation of separation of powers because none of these state legislatures has delegated to the executive branch the role of creating the law.

Can the legalization of marijuana (but not marijuana vaping products) and the removal of restrictions on its consumption in a majority of the states decrease the use of tobacco and related products?

I don't know. I am not aware of any data that have examined the impact of the legalization of recreational cannabis use on the consumption of tobacco products.

I am late to the discussion but what are your thoughts on the news of a lawsuit over alleged contaminated JUUL pods? Why don’t they list what made it contaminated? If these actually were contaminated, will we ever find out where these were distributed, sold, and purchased? I ask this because it seems like par for the course on this entire situation with lack of information. I find it frustrating and was curious your thoughts

I read the lawsuit complaint and it never mentioned what the contaminant was. That makes me a little bit suspicious because if the contaminant were known, one would think they would have included that in the complaint. My sense is that whatever the contaminant, it probably didn't have any substantial health implications, but the very idea that the company would ignore it drove the employee to file this suit. It's possible that in the discovery process, more details will come out.

What are your thoughts on ejuice companies that use child appealing labels on their bottles? Do you think that the vape industry and the anti-vape organisations can come to a compromise by allowing flavored ejuices to remain on the market, but with heavy restrictions on marketing?

See this image : https://i.imgur.com/lVMKmjx.png

I think it's unfortunate that some companies have chosen to use child-appealing labels. I think your suggestion would be a great compromise position, and is the type of actual regulation of the product that I believe we need instead of prohibition.

how does this jive with the theory that the recent uproar and action over <50 people is just grandstanding and trying to get rid of vaping to recover money lost from lack of cigarette sales?

tobacco master settlement bonds are due and shipments are down so they cant pay back the cash they took out against projected earnings.

thank you for your work!

While I do think there were actions that states took because of the MSA money, I think that we don't need to go so far to explain what is happening with these bans. I think that it is politically expedient to make it look like you are concerned about kids by banning flavored e-cigarettes, while shoving smokers and adult vapers under the bus, because it is not going to cost you politically for doing so. So in this case, I think it's political expediency more than economic concerns.

Do you think its worse in terms of health and volume of smokers than before vaping was a thing?

All in all, I think e-cigarettes have been a huge, net positive for the public's health and have contributed towards an acceleration in the decline of cigarette smoking, both among youth and adults. Unfortunately, because the FDA chose a prohibitionist approach instead of regulating the product properly, the situation got out of hand among youth after the introduction and widespread popularity of JUUL. That has set us way back and it's not clear whether the market will be able to recover from it. I kind of wish the market only consisted of vape shops!!!

-How THC (marijuana) vapes and black-market products are contributing to the widespread vaping-related injuries and deaths

Is this to say that there are NO safe marijuana vapes? Or ONLY black-market AKA homemade ones can be dangerous? I wish it was just legal so we weren't even talking about this

I think it's safe to use most legal THC vapes, but apparently there are a small number of vitamin E acetate-containing THC vaping products that made it into the legal market in some states (particularly Oregon and Washington). Most states are now testing their products for vitamin E acetate oil so the legal supply of THC vapes should be pretty safe. There also may be some legal CBD oils that are involved, so caution should be exercised in purchasing those products as well.

I have two questions if you don’t mind:

If vaping is the problem, wouldn’t other countries be having the same problems as well? I haven’t heard anything about illness or death from other countries, making me think the difference in the case for the US is the use of illegal carts and the chemicals in those.

Edit: also I realized that vaping has been around for years, so why is the scare now? I think it’s more than conviennent that illegal cannabis carts have become so popular lately and now is when the “vaping epidemic” is. If it were truly a vaping epidemic wouldn’t there have been instances of illness linked to e-cigarette use years before illegal carts were popular?

Do you think there is a risk of lung injury/serious illness from vaping regular juice, from reliable companies? Should I be concerned about my risk of lung injury strictly vaping legal vape juice?

I think you answered your own question. The difference is that in the US there are lots of illegal carts, especially in the THC market and there are a smaller number of legal THC/CBD e-liquids that apparently had vitamin E acetate in them as a thickening agent, or a similar contaminant. I think it's extremely unlikely that legal nicotine-containing vape juice is playing a role in this outbreak; however, there are apparently a small number of legal THC/CBD oils that may be involved.

What’s up Doc🥕! What can you tell about the tobacco heating systems like IQOS or Glo? I live in Kazakhstan and these things are getting really popular here and in Russia.

The problem with the heat-not-burn products is that they still contain tobacco and when tobacco is heated it still releases hundreds if not thousands of chemicals, including human carcinogens. The levels of most of these chemicals are lower than in tobacco smoke, but still much higher than in e-cigarettes. So this raises the question of what value these products have over e-cigarettes. My personal opinion is that with tobacco-free e-cigarettes, there isn't really a need for heat-not-burn tobacco products.

I looked at the recent CDC data and it seems the EVALI case are plummeting even though they say it's due to a "reporting lag." Do you believe the lung illnesses, especially the deaths, are mostly over?

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#epi-chart

It did look like the cases were dropping last week; however, yesterday's numbers did not show a continuing decline. So it's not clear to me yet that the outbreak is subsiding. However, it does appear that thanks to the great work of David Downs and others at Leafly, word is getting out on the streets of Los Angeles that we're onto them and that they shouldn't continue to use Honey Cut or other oils with vitamin E acetate as a thickener. That, more than anything that the CDC is doing, is probably going to be the single most important action that curtails the outbreak.

There’s a market (I’m sure you know, obviously) for smoking cessation (e.g., patches, gum, etc.). Do you foresee vaping to have a cessation market for itself? Do you foresee it ever getting that big that it would require such a market?

Because it takes an average of about 8 years for a drug to gain FDA approval as a smoking cessation product, and because there are very few e-cigarette companies that have the kind of capital to be able to afford to conduct the clinical trials that would be necessary, there really is not much of a chance that we are going to see e-cigarette companies take that route. The tobacco companies could potentially do that at some point, but I don't think it's likely. It's also unlikely that pharmaceutical companies would do it because they already are marketing smoking cessation products. I think the most likely scenario is that e-cigarettes will remain regulated under the Tobacco Act (as tobacco products and not drugs), but it will be mostly tobacco companies that control the market.

Good afternoon Dr. Siegel!

Thank you so much for your efforts. I began vaping two years ago after three unsuccessful attempts to quit smoking, and it has honestly changed my life. I can't imagine ever touching a cigarette again. I've been following your blog for a few months now, and it's been great seeing a public health professional taking an objective look at the facts, and looking for ways to curb youth nicotine addiction without harming adults who are trying to recover from addiction to combustibles.

Regarding the EVALI outbreak, are you aware of any studies or organizations that are accepting samples of vaping products (both nicotine and THC) for testing? I recall a website around the turn of the century called erowid.org that hosted sample testing for ecstasy and other drugs, in order to raise awareness of batches that might be tainted or unsafe. I've been wondering if something like that exists or is being considered for vaping products, whether for public use or simply to gather additional data to help pinpoint the cause or causes of EVALI. Thanks!

The CDC is accepting samples for testing from outbreak case patients. But I am not aware of any effort to do general testing of e-liquids outside of the outbreak cases. But I think it's a great idea and would help greatly to identify the specific causes of the outbreak.

Going off of this question- do you know if any products are being tested? I’m not in the medical field but I would assume a logical step in this process should be to test some of the most popular juices and start ruling stuff out? Maybe this is just info they don’t make public until they know for sure??

The CDC and FDA are testing products. But so far as I know, they are only testing cartridges that have been recovered from case patients. They are not doing a more general investigation of products on the market.

Interestingly, one of the news outlets did do an investigation. They purchased 10 THC vape carts off the black market and had them tested. All of them contained very high levels of pesticides.

I don't understand why the FDA and CDC aren't in Los Angeles right now walking from wholesaler to wholesaler and testing their cartridges. They could probably have an answer to this in 2 days if they actually went to the "source" of the problem.

Hi Dr Siegel

First off I also want to thank you for everything that you’re doing to help fight for vaping, with how MA is treating this it’s good to know there is someone in these parts that Is really fighting for actual public health. I was a smoker for 10 years before I switched to vaping 3 years ago, completely smoke free and feeling much healthier! My question is what do you think the likelihood is of this MA vape ban being extended?? It’s so discouraging that even with all the evidence that it will do more harm than good and even agreement from the judge that it’s probably not legal products (or so I read), it’s still allowed to stand.

My guess is that rather than extending the vape ban, the administration will try to get the legislature to enact a legislative ban on flavored e-cigarettes. I think they will allow tobacco-flavored e-cigarettes back on the market.

Have you smoked or vaped and attempted to stop? Or only studied people who have?

No - I have never smoked or vaped myself. I have just studied people who have, and also I have treated people who smoked or used other drugs (this was in the context of working in an addiction treatment program).

Good afternoon, Dr. Siegel! As a young man who began vaping to aid in quitting cigarettes, have you personally seen dramatic improvement in lung health after individuals made the switch? Additionally, have you personally seen any lung damage in individuals who have only exclusively vaped and never smoked traditional cigarettes?

Dr. Riccardo Polosa has done some excellent research on changes in lung health among smokers who switch to vaping. He and his colleagues found evidence of dramatic improvement in lung health among smokers who made the switch. You can find one of his papers here: https://www.nature.com/articles/s41598-017-14043-2.

As far as nonsmokers who vape, I'm not aware of evidence of lung damage outside of the current outbreak, which doesn't seem to be related to traditional e-cigarettes, but to THC and black market products.

Hello /u/mbsiegel ! Thank you for taking the time to do this. I use cannabis fairly regularly in whats considered a "dry-herb" vaporizer. I basically stuff the herb into the vape and pull. Are the respiratory problems stemming primarily from the oils or are dry herbs also on the table?

Basically, did I do wrong using only herb over oils?

Thanks again!

The problem most definitely appears to be the oils, not the herb itself. From what we know, vaping the dry herb or cannabis flower is not a risk factor for this outbreak.

Why do you think the evidence insufficient for the CDC that tocopheryl acetate is responsible?

I am not concluding that tocopheryl acetate oil itself is responsible or that this is the only thing involved because they have not identified any specific chemical in the THC oil that can be implicated in the respiratory toxicity. However, I do think there is enough information to conclude that THC vaping cartridges, especially those sold on the black market, are playing a major role in this outbreak. It doesn't matter what specific chemical is involved in terms of crafting a message to send to the public. The CDC has finally started to send that message, but they still continue to undermine it as well.

Should CDC Director be replaced for failing to identify the cause after 3 months of investigation?

No. I don't actually blame CDC for failing to identify the cause. What I blame them for is having IDENTIFIED the cause but taking about eight weeks to inform the public about it. And then even after telling the public about it, continuing to undermine their own conclusion.

I think there's a difference between identifying what product (in general terms) is causing the outbreak and what the specific chemical is that is causing the outbreak. But the key point is that you don't need to know the latter in order to know the former. And if you know the former, you have enough information to craft a specific, clear, and effective warning to the public. Very few state health departments are doing that.

Do you think lying or manipulation of data, about health effects, statistics, etc., by anti-smoking/anti- vaping lobbyists and activists has inhibited fact based policy making and reasonable regulation? Or have you found both sides of the debate to be pretty reasonable?

By the way, I will add, I am in strong agreement with the stances you've voiced here today. If you can let me know how to get involved I would appreciate it.

Yes - I absolutely think that the misleading of the public about the health effects of electronic cigarette use has inhibited evidence-based policy making and reasonable regulation. It has created a situation where electronic cigarettes are being much more stringently regulated than their highly toxic real cigarette counterparts. This makes absolutely no sense, and there is no public health justification that supports this kind of policy.

I think the most effective way to get involved is to share your story with policy makers, especially with the president, the FDA, and state governors and health departments in states that are considering bans. The more policy makers hear from actual vapers who understand the value that e-cigarettes have played in improving their health, the more likely we are to avoid the really harmful public policies that are becoming all-too-common.

Is vaping medical marijuana concentrate dangerous?

Generally speaking, I view the vaping of marijuana concentrates as being risky. First, the THC concentration is extremely high and so the use of these products can lead to extreme mental health effects such as agitation and rapid heartbeat or even psychosis, paranoia, or blackouts. Second, the concentrate is often extracted with butane - if the person is doing the extraction themselves, there is the risk of explosions. Third, if not carefully prepared, there can be residual butane left in the concentrate. Fourth, there have been reports of severe pneumonitis associated with the use of butane hash oil, leading to respiratory failure (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327978/). Finally, there are cheap vape pens on the market that could expose the user to heavy metals.

With that said, there are people who really know what they are doing who are using high-quality vape pens with concentrates produced by dispensaries that are regulated, with testing for butane (and maximum allowable residual butane levels) that may be relatively safe. So for "experts," it might be OK, but generally speaking it is not particularly safe - it's not something, for example, that any youth should be doing.

All in all, I think using the flower is much less risky or using a distillate that is properly made (and was not cut with vitamin E acetate oil or other dangerous oils).

I ask this question purely from the perspective of a user, not as a manufacturer (though I do hope the mom & pop's win in the end)...

Do you foresee a future where Big Tobacco ends up in majority (or full) control of the vaping market, then the industry is "miraculously" regulated and approved for public consumption?

I suspect this is how it will all play out.

Yes - this is precisely what I think is going to happen. The problem is that such a market will be much smaller than the current market and there will not be a diversity of products. Nor will there be vape shops. There will, however, be a huge increase in black market and DIY products. Ironically, there will likely be more unregulated products out there than regulated products!

What should patents do of they realise their children are vaping? What resources are out there for teens who vape and want to quit?

Edit: I would like to mention that I don’t vape... (and also I’m a high schooler)

This is a complex issue. I think it depends on the individual situation and what the youth is vaping. If a youth is vaping JUUL and is not able to quit cold turkey, it might actually be helpful to have them switch to an e-cigarette that doesn't use a nicotine salt -- perhaps starting at around 20 mg/mL of nicotine and then gradually weaning them off until they are down to 0, and at that point, it should be much easier for them to quit completely. If the youth is not using a nicotine salt, then it shouldn't be that difficult to quit abruptly or to wean down the nicotine quickly.

Julia Belluz at Vox wrote a nice article about quitting JUUL for youth: https://www.vox.com/2019/10/11/20907711/juul-nicotine-addiction-how-to-quit-vaping. The bottom line is that there are no proven techniques or studies to rely upon because this is so new. All I can say is that if it were my child, I would start with an attempt to quit cold turkey, but if that doesn't work, I would switch my child over to a relatively high-nicotine e-cigarette (not a salt formulation) and then have them gradually wean down.

I'm curious why you're so against the flavor ban if your reason for defending vaping is it helps smokers quit. They dont make flavored cigarettes, so why would we need flavored e juice? I'm a current smoker so not judging but it seems to me that most smokers wouldnt need a flavor, flavors would only help get not smokers to start bc they like the taste.

I understand why one would think that; however, the market sales data demonstrates that the overwhelming majority of adult vapers use non-tobacco-flavored e-liquids. One of the reasons why smokers switch to vaping is specifically to get away from tobacco. So the idea of using a tobacco-flavored e-liquid doesn't appeal to many smokers. Moreover, once they do switch to a flavored e-liquid, they lose their taste for tobacco and don't want to go back. Data from a study of JUUL users demonstrates that smokers who switched to flavored JUUL pods were significantly more likely to quit smoking completely than those who switched to tobacco JUUL pods. So the flavors appear to also increase the effectiveness of e-cigarettes for smoking cessation.