Vaping

Mar 07, 2024

Sources

 

Can vaping damage your lungs? What we do (and don't) know

  • 14% of teenagers vape
  • What is vaping?
    • Vaping involves heating a liquid and inhaling the aerosol into the lungs. With vaping, a device such as an e-cigarette is used that heats up a liquid (called vape juice or e-liquid) until it turns into a vapor that is inhaled. These devices are commonly called vapes, mods, e-hookahs, sub-ohms, tank systems, and vape pens. They may all look a bit different, but work in similar ways.
  • Vapes contain nicotine
    • These devices heat up various flavorings, nicotine, marijuana, or other potentially harmful substances. A CDC study found that 99% of the e-cigarettes sold in assessed venues in the United States contained nicotine.
  • Toxins in vape liquid
    • nicotine
    • ultrafine particles that can be inhaled deep into the lungs
    • flavorings such as diacetyl, a chemical linked to a serious lung disease
    • volatile organic compounds
    • cancer-causing chemicals
    • heavy metals such as nickel, tin, and lead.
  • 68 people died from vaping
    • More than 2,800 e-cigarette users required hospital admission due to EVALI through February 2020; 68 of these people died. Most cases were among teens and young adults.
    • Typically, symptoms have started gradually, with shortness of breath and/or chest pain before more severe breathing difficulty led to hospital admission.
  • Vitamin E contamination in vapes
    • Experts now suspect contamination with a form of vitamin E (called vitamin E acetate) in some tetrahydrocannabinol (THC)-containing e-cigarettes as the cause of EVALI. Other contaminants and other factors (such as pre-existing lung disease) may also play a role.
    • The number of new EVALI cases has declined dramatically since September 2019, probably due to public health messaging about a link between THC in e-cigarettes and EVALI, and removal of vitamin E acetate from e-cigarettes. However, it's also true that some cases of EVALI may be missed (such as those attributed to infection) and tracking of cases is incomplete.
  • Popcorn lung
    • "Popcorn lung," or bronchiolitis obliterans (BO), refers to a type of inflammation in the lungs that causes wheezing, coughing, and shortness of breath. Over time, it can lead to scarring of the lungs' tiny air sacs, along with thickening and narrowing of the airways. A chemical called diacetyl, found in many e-cigarette flavors, is one cause of this condition. The name comes from reports of the illness due to diacetyl among workers in a microwave popcorn factory.
  • Nicotine is addictive
    • Nicotine from vaping. Nicotine is highly addictive and can affect the developing brain, potentially harming teens and young adults. Even some "nicotine-free" e-cigarettes have been found to contain nicotine. Accidental exposure to liquid from e-cigarettes has caused acute nicotine poisoning in children and adults.
  • Can cause cancer
    • Cancer risk and vaping. Some substances found in e-cigarette vapor have been linked to an increased risk of cancer. The aerosol that users inhale and exhale from e-cigarettes can expose both themselves and bystanders to harmful substances.
  • Explosions and burns from vaping
    • Other risks of vaping. Explosions and burns have been reported with e-cigarettes while recharging the devices, due to defective batteries. In addition, vaping during pregnancy could harm a developing fetus.

 

What Does Vaping Do to Your Lungs?

  • More and more people are getting illnesses from vaping
    • “In the last 24 to 36 months, I’ve seen an explosive uptick of patients who vape,” reports Broderick. “With tobacco, we have six decades of rigorous studies to show which of the 7,000 chemicals inhaled during smoking impact the lungs. But with vaping, we simply don’t know the short- or long-term effects yet and which e-cigarette components are to blame.”
  • How vaping works
    • Both smoking and vaping involve heating a substance and inhaling the resulting fumes. With traditional cigarettes, you inhale smoke from burning tobacco. With vaping, a device (typically a vape pen or a mod — an enhanced vape pen — that may look like a flash drive) heats up a liquid (called vape juice or e-liquid) until it turns into a vapor that you inhale.
    • “Vaping is a delivery system similar to a nebulizer, which people with asthma or other lung conditions may be familiar with,” says Broderick. “A nebulizer turns liquid medicine into a mist that patients breathe in. It’s a highly effective way of delivering medicine to the lungs.”
    • Instead of bathing lung tissue with a therapeutic mist, just as a nebulizer does, vaping coats lungs with potentially harmful chemicals. E-liquid concoctions usually include some mix of flavorings, aromatic additives and nicotine or THC (the chemical in marijuana that causes psychological effects), dissolved in an oily liquid base. “We think that some of the vaporized elements of the oil are getting deep down into the lungs and causing an inflammatory response,” explains Broderick.
  • Damage caused by vitamin E
    • The substance at the center of investigation is vitamin E. It’s often used as a thickening and delivery agent in e-liquid. And, while it’s safe when taken orally as a supplement or used on the skin, it’s likely an irritant when inhaled. It’s been found in the lungs of people with severe, vaping-related damage.
  • Toxins in vapes
    • Diacetyl: This food additive, used to deepen e-cigarette flavors, is known to damage small passageways in the lungs.
    • Formaldehyde: This toxic chemical can cause lung disease and contribute to heart disease.
    • Acrolein: Most often used as a weed killer, this chemical can also damage lungs.
  • Popcorn lung
    • “Popcorn lung” is another name for bronchiolitis obliterans (BO), a rare condition that results from damage of the lungs’ small airways. BO was originally discovered when popcorn factory workers started getting sick. The culprit was diacetyl, a food additive used to simulate butter flavor in microwave popcorn.
    • Diacetyl is frequently added to flavored e-liquid to enhance the taste. Inhaling diacetyl causes inflammation and may lead to permanent scarring in the smallest branches of the airways — popcorn lung — which makes breathing difficult. Popcorn lung has no lasting treatment. There are, however, treatments that manage BO symptoms, such as:
    • Coughing
    • Wheezing
    • Chest pain
    • Shortness of breath
  • Vaping pneumonia
    • Unlike the classic pneumonia caused by infection, lipoid pneumonia develops when fatty acids (the building blocks of fat) enter the lungs. Vaping-related lipoid pneumonia is the result of inhaling oily substances found in e-liquid, which sparks an inflammatory response in the lungs. Symptoms of lipoid pneumonia include:
    • Chronic cough
    • Shortness of breath
    • Coughing up blood or blood-tinged mucus
    • “There’s isn’t a good treatment for lipoid pneumonia, other than supportive care, while the lungs heal on their own,” says Broderick. “The single-most important thing you can do is identify what is causing it — in this case vaping — and eliminate it.”
  • Collapsed lung after vaping
    • Primary spontaneous pneumothorax, or collapsed lung, occurs when there’s a hole in the lung through which oxygen escapes. This can be the result of an injury — such as a gunshot or knife wound — or when air blisters on the top of the lungs rupture and create tiny tears.
    • Those who develop these blisters are usually tall, thin people who had a period of rapid growth during adolescence, says Broderick. Because of the accelerated growth, a weak point may blister and develop at the top of the lungs. On their own, these blisters don’t typically produce symptoms. You don’t know you have them, unless they rupture. Smoking — and now vaping — are associated with an increased risk of bursting these blisters, leading to lung collapse.
    • “At Johns Hopkins, we’re seeing a rash of collapsed lungs in younger people,” reports Broderick. “We always ask if they’ve been smoking, and they’ll often say, ‘No, I don’t smoke. But I do vape.’ Now we tell patients not to smoke or vape if they want to avoid another lung collapse and surgery in the future.”
    • Sharp chest or shoulder pain
    • Shortness of breath
    • Difficulty breathing
    • Oxygen treatment and rest may be all that’s need for a collapsed lung to heal. But more advanced cases require a chest tube to drain leaked oxygen from the body cavity or surgery to repair the hole in the lung.
  • Second hand vape isn’t dangerous
    • It’s a myth that secondhand emissions from e-cigarettes are harmless. Many people think the secondhand vapor is just water, but this couldn’t be farther from the truth. The vapor emitted when someone exhales contains a variety of dangerous substances, which may include:
    • Nicotine
    • Ultrafine particles
    • Diacetyl
    • Benzene (a chemical found in car exhaust)
    • Although secondhand vapor may not affect the lungs the same way as vaping, it is better to avoid it, if possible.

 

The Dangers of Vaping

  • The invention of the vaporizer
    • The invention of vaping is attributed to Herbert Gilbert, a cigarette smoker and scrap metal dealer from Pennsylvania. Gilbert’s device was battery-powered to vaporize a liquid for inhalation, very similar to modern electronic cigarettes. He admitted to the Smithsonian magazine that he believed it to be a breakthrough alternative to cigarette smoking to save people from tobacco’s harmful effects as it did not contain nicotine. 
    • After multiple permutations, the device was never mass-produced but its patent has been cited by many companies since then. He actually proposed an alternative use for the device for people that were dieting and believed that they could vaporize the tastes of their favorite foods to quench food cravings. He initially proposed a handful of flavorings including cinnamon, rum, orange, and mint.1–2 A year after the patent was submitted in 1963, the Surgeon General Luther Terry released his report “Smoking and Health” on the potential health consequences of cigarette smoking. This was the first report implicating cigarettes in a causal relationship with lung cancer and heart disease as well as laryngeal cancer and chronic bronchitis.3
  • Vaping was seen as healthier
    • In 2019, vaping tobacco is a new gateway to nicotine abuse that frequently skips the initial phase of addiction to cigarettes. It has been perceived as safer, better tasting, more efficient, and more discrete. Vaping tobacco provides new users with an overall better initial experience when compared to the first time smoking cigarettes
  • Vaping has been normalized
    • Eighty years ago, cigarette smoking was culturally accepted and even considered “cool.” In the present day, vaping tobacco has its own culture that is often separate from cigarette smoking. Substantial marketing investment by tobacco companies in response to a decrease in combustible cigarette consumption in the last few years has led to an overall normalization of vaping tobacco and a change in perception that it is safe.
    • Combustible cigarette smoking has become culturally stigmatized, with many cities outlawing tobacco smoking in bars and restaurants and sometimes even on the street. Vaping is a method by which people can consume tobacco products without being part of a fringe and marginalized group
  • People vape marijuana
    • The legalization of marijuana has drastically changed the landscape of the use of this drug, both in terms of the potency of available products and the methods by which it can be ingested or inhaled. In states where marijuana has become legal, vaporizing marijuana oils is more convenient and more popular
  • Vape liquid is not regulated
    • The pharmacologically active components of vaping products are not regulated, and the methods by which they are extracted and suspended in solution vary greatly. 
  • Propylene glycol can cause asthma
    • The conventional solvents for the dissolution of nicotine or THC have been propylene glycol and glycerol, and these are the best studied. Initially thought to be benign, there is now some research demonstrating that propylene glycol when vaporized causes significant respiratory irritation and even increases the incidence of asthma. 
  • Propylene glycol breaks down into formaldehyde
    • The breakdown products from heating propylene glycol and glycerol to target temperatures include formaldehyde and hemiacetals such as acetaldehyde. Formaldehyde is a Group 1 carcinogen that contributes a 5–15 times higher lifetime risk of cancer. It is present in traditional smoked tobacco in much lower quantities.
    • Hemiacetals such as acrolein and acetone have been implicated in nasal irritation, cardiovascular effects, and lung mucosal damage and these byproducts are produced in higher quantities with higher voltage devices. Basically, as the temperature of the coil increases, the carcinogenic risk of vaping approaches that of traditionally smoked cigarettes
  • Flavorings in vapes cause bronchitis in factory workers
    • The flavorings added to the nicotine and THC extracts represent a separate but no less worrisome health risk. We tend to think of food additives as safe, and we sometimes learn empirically about the hazards they pose when people are exposed to them in ways other than direct ingestion. Diacetyl is a food additive that is also used in flavoring electronic cigarettes that approximates the flavor of butter. In the early 2000s, diacetyl was implicated as a cause of bronchiolitis obliterans organizing pneumonia (BOOP) in factory workers exposed to it in large quantities. 
    • Although it is considered safe to eat, exposure to this chemical is regulated and limited by OSHA due to its proven health effects.8,19 The flavoring additives of electronic cigarettes on the mass market are typically passed through the FDA under a provision that these chemicals, almost exclusively synthetic, are “generally accepted as safe” for human consumption. The caveat with this provision is that consumption refers to oral ingestion. It is unknown what potential health effects result when something perfectly safe to eat and digest is vaporized at 500 degrees and inhaled. 
    • Some research is demonstrating that the flavorings incorporated into electronic cigarettes have cytotoxic effects.8 Furthermore, sweeter flavorings tend to contain stronger oxidizers. One study used a murine model of lung epithelial cells and demonstrated a higher release of inflammatory cytokines IL-6 and IL-8 as well as fibroblastic changes in the subjects exposed to sweeter electronic cigarette flavorings, with the mice appearing to lose redox balance.20
  • Vitamin E can cause lung injury
    • Recent research has shown that Vitamin E is a new solvent into which these THC extracts are dissolved, probably due to its relative ease of acquisition. All of the health effects of inhaling vaporized vitamin E are unknown.21 There is recent evidence that vaporized vitamin E oil may be a cause of Electronic cigarette and Vaping Associated Lung Injury (EVALI).
  • Burns from vaporizers
    • The simplest and highest-yield method of extracting THC oil from marijuana buds utilizes a rudimentary setup that exploits certain properties of compressed butane gas, called “supercritical fluid extraction”. The traditional backyard equipment setup is a PVC pipe and a butane lighter refill canister which, under the right conditions, can explode with multiple case reports of severe burns. Most of those who self-report home extraction of THC oil learned how to do so from materials available on the internet, and by watching videos on Youtube
  • People getting addicted to vaping
    • It bears noting that when vaping is successful and delivers concentrated nicotine or THC to the user, the amount of drug delivered is much higher than would typically be inhaled by burning and smoking the raw tobacco or marijuana plant. Sociological questionnaires on vaping habits reveal a trend toward dabbing THC contributing to addictive behavior not reported by those users who smoke marijuana in a non-concentrated form. The same pattern of addiction, tolerance, and withdrawal that has been observed in drugs like heroin, traditionally considered “hard drugs”, is now being reported in those vaping THC
  • Nicotine poisoning from vapes
    • There have been some cases of nicotine poisoning from using electronic cigarettes, with an increased risk of toxicity associated with customized devices and higher nicotine concentrations in the liquids. Finally, many of those who attempted to quit cigarettes by transitioning to vaping are reporting that quitting vaping is actually significantly harder than quitting smoking traditional cigarettes, with some respondents even turning back to cigarettes as a way to help wean off their vaporizer device
  • Vaporizing is supposed to be safer
    • The basic design of the device, in the case of vaping both tobacco and marijuana, is largely unchanged from the original patent by Gilbert. There is a reservoir that holds an oil or liquid, a mouthpiece, and a heating element. Theoretically, vaporizing the liquid does not combust it and saves the person vaping from exposure to byproducts generated by high heat.
    • However, there is no regulation of these devices and no agreed upon standard temperature. There appears to be a wide variance in the quality of the components of these devices depending on the price of purchase
    • There are multiple different metals used for the heating element, including: Nichrome (nickel-chrome), tungsten, stainless steel, and Kanthal (Ferritic iron chromium aluminum alloy) among others. Powered by a battery, the element wire is heated to a temperature range around 375–525 degrees. The long term effects of sustained exposure to the oxide products of these metals are unknown
  • People make their own vapes, but that can be dangerous
    • There are manufactured electronic cigarettes under various brand names (Figure 1), but there is also a subculture of people who vape either tobacco and marijuana (or both) through devices that they custom build, referred to as “mods”. There are many websites and physical stores catering to this hobby, and there are many different accessories and components available to change different aspects of device performance. A user can find stronger batteries, a wide array of device designs, and an even broader selection of metals for the heating element in different lengths and diameters. The practice of “direct dripping” involves users directly dripping the vaping liquid onto a heated coil with the express intention of increasing the quantity of vapor as well as increasing the concentration of the active ingredients being vaped.6,16,20,29 This practice increases toxin exposure and often goes along with modified devices that increase temperature by increasing voltage
    • Increasing the voltage of the device with stronger batteries and driving higher temperatures on the heating coils has been shown to approach equivalency with cigarettes in terms of exposure to carcinogens. It is unknown what other potential health effects are caused by modifying these properties of the device
  • There are reports that vaping is dangerous
    • The smoking of tobacco in pipes and cigarettes used to be much more common, and it took a long time to realize the true dangers of combustible cigarette smoking. The terminology used can be confusing (Figure 2). The available body of medical literature regarding the potential harms of vaping consists of data from animal models, observational studies with small numbers of subjects, and single case reports and series. One observational study utilized pulmonary function tests to show that vaping decreases FeNO and increases respiratory impedance.30 There have been multiple case reports of vaping-associated lipoid pneumonia. As previously mentioned, there have been reports of both THC and nicotine toxicity. There are many reports of mechanical injury and burns from malfunctioning devices. The perception that vaping is safe is starting to change.



Doctors increasingly discourage vaping amid mounting health concerns

  • Side effects of vaping
    • Even in young people, e-cigarettes have been shown to "increase heart rate, blood pressure and affect the ability of the blood vessels to relax," said Dr. Naomi Hamburg, Cardiologist and Professor of Medicine at Boston University. Using an alternative option that has been proven to be safe is ideal.
  • Vaping can damage lungs
    • A medical condition called EVALI – E-cigarette or Vaping-use Associated Lung Injury - not only causes damage to the lungs but can also cause issues in other organs' systems.
    • A CDC evaluation found that ingredients associated mostly with illicit THC vaping products played a major role in the 2019 EVALI outbreak that peaked in September 2019.
    • The FDA says e-cigarettes have been found to contain lower levels of harmful chemicals compared to conventional cigarettes, but that no tobacco products are considered safe.
  • 17 year old developed EVALI
    • Frances Daniels, a parent and volunteer at Parents Against Vaping, details the harrowing experience of watching her then 17-year-old who used e-cigarettes recreationally struggle in the Intensive Care Unit for 5 weeks after being diagnosed with EVALI in 2020.
    • "At some point they had 6 different chest tubes and was placed on a waitlist for transplants," Daniels said.
    • Fortunately, Daniels' child was able to make a full recovery without needing a lung transplant months after leaving the hospital, but the experience remains difficult to think and speak about.
  • Vape makers say it’s a good alternative to smoking
    • The American Vapor Manufacturers, which represents independent vapor manufacturers across the United States, insists e-cigarettes can be an effective smoking cessation tool and says on its website that "We care deeply about the Right to Switch because so many of our entrepreneurs, manufacturers, retailers, and workers around the country quit by switching themselves."

 

The FDA stands by as the vaping industry flouts its orders

  • FDA hasn’t approved of vapes but they’re allowed to be sold
    • Take EJuiceDB.com, a website that sells over 7,000 vape liquids. The FDA hasn’t formally greenlit a single one of those flavors, meaning they’re all technically illegal. But in several cases, the agency has gone further and explicitly banned certain products — and they’re still for sale, too. A banned “sunset sherbert” flavor, for example, is one of the site’s best sellers.
    • It’s not just flavored liquids, either. For instance, Wizman Limited, a Hong Kong-based company, is still selling a vape holder shaped like a Gameboy, even though the FDA banned it two years ago, saying teens might use it to hide vaping from their parents.
    • STAT’s investigation examined the main way the FDA has tried to crack down on vape companies selling illegal products. It’s ordered more than 100 vape manufacturers to stop making more than 250 specific flavors and vapes — but we found scores of companies, across the country, that are defying the FDA’s demands.
  • FDA doesn’t care to monitor vape companies
    • The reporting reveals, too, just how reluctant the FDA is to use its power to rein in bad actors. The agency has sweeping legal authorities to crack down on vape companies that ignore its bans, ranging from levying seven-figure fines to physically pulling products off shelves. But the FDA has never used those powers, according to its own data. In several cases, it’s even dropped cases against companies that it knows are still selling illegal products.
    • The agency’s approach has been so conservative in certain cases that one legal expert compared it to a cop pulling someone over for running a red light while drunk — and then writing them a ticket for the traffic violation and sending them on their way.
  • Statement by FDA
    • “The agency is currently working on further enforcement in situations where companies that have [been banned from the market] continue to sell illegal products,” the spokesperson wrote in an email. “The FDA is currently engaged in discussions with the Department of Justice (DOJ) regarding specific potential enforcement actions.”
    • \Vape shops, for their part, argue that the FDA’s orders aren’t clear enough. Until they understand exactly what’s illegal and what’s not, they’ll keep operating.
  • It’s a filing problem
    • “[Vape shops] are doing their best, despite a complete lack of clarity or transparency from the agency, to piece together what products are still legally able to be sold,” said Amanda Wheeler, the president of the American Vapor Manufacturers. “It would be legally and morally irresponsible for us to recommend that companies should voluntarily close down their businesses because FDA cannot sort out their filing systems.”
  • How the FDA regulates vapes
    • The way the FDA regulates vapes and vape liquids was shaped both by Congress’s 2009 law empowering it to regulate tobacco and a regulation — fiercely opposed by vape shops — that extended the rules governing cigarettes and cigars to e-cigarettes. Technically, every company that manufactures a vaping product — whether that’s mass-producing millions of disposable e-cigs in a Chinese factory or mixing up e-liquid in the back of a corner-store shop — is supposed to get the FDA’s permission before selling its wares stateside.
    • Originally, companies were supposed to ask FDA’s permission to sell by November 2018, a step also known as filing an application with the agency. But the FDA and a federal court pushed that deadline to September 2020.
  • Vapes were being sold without permission
    • In the intervening years, countless companies sold their products without FDA permission, and the vaping industry boomed. Juul grew from a small, 200-person company to a $15 billion enterprise with a 1,500-person workforce. Overall, e-cigarette sales increased six-fold, from $304.2 million in 2015 to $2.06 billion in 2018, according to a recent government study.
    • STAT’s investigation likely underestimates the level of intransigence among vape companies because it focused on those that have shown themselves most willing to play by the FDA’s rules. STAT only analyzed warning letters sent to companies that formally asked the agency for permission to sell their products, and then had that request denied. It did not focus on the hundreds more companies that received warning letters for never asking the FDA for permission at all.
    • The review also did not count products in its tally when it was impossible to determine whether the manufacturer was making the product illegally or if the retailers were simply selling leftover stock of a discontinued product. More than 30 other banned products are still available online through third party sellers, for example.
    • Take, for example, Rocky Top Vapor, which operates five stores in Tennessee. The FDA ordered that company to stop selling its Berry Shake and Pink Lemonade vape juice in April 2021. This July, the agency sent them a so-called “close-out letter” because Rocky Top had stopped selling those two products. But just one paragraph later, the letter makes it clear the FDA knows Rocky Top is still selling other products that it hasn’t greenlit.
  • When they do try to regulate the vapes, the companies don’t listen
    • Last year, the FDA finally started formally denying some companies’ requests to sell their products. In many cases, the companies just ignored them, complaining that the regulatory process was too burdensome or even “over-reaching.”
  • FDA moves too slow
    • Eric Lindblom, a former FDA official who is now a senior scholar at Georgetown University, argued that the FDA’s slow piecemeal approach is enabling bad behavior from vaping companies.
    • Even some people who support vaping as an alternative to smoking were also alarmed by the findings. They argued that the industry’s intransigence and the FDA’s lack of action could actually hurt the effort to expand access to vaping.
    • It’s not an easy thing for the FDA to seize a company’s products or shut them down entirely. The FDA typically works directly with the Justice Department to make a legal case against a bad actor – and that process takes time. It took the FDA two years, for example, to ask a court to shut down a company that sold illegal sexual enhancement supplements.
    • The FDA, across its entire portfolio of food, drugs, and supplements, has sought 15 injunctions and conducted two product seizures in the last two and a half years. Not a single one has involved a tobacco company.
  • Companies can file appeals when their product gets banned
    • She noted, for example, that many companies have tried to file “administrative appeals” with the FDA, challenging the agency’s decisions on their products. But the FDA never formally decided how to respond to those requests. (The FDA does not disclose which companies file such appeals, so it is impossible to say definitively how many companies have done so.)
    • She also argued that multiple companies whose products the FDA had banned had filed new applications with the agency when they started making products with nicotine cooked up in a lab, rather than extracted from a tobacco leaf. Those new requests haven’t yet been denied, so they believe they should be allowed to keep selling in the interim. (Technically, this is also illegal.)
  • The FDA only sends letters
    • The agency ordered the Tennessee-based vape shop Nashville Vapor to stop selling two products in October 2021. And then it issued a so-called “close-out letter” this July, saying “it appears that you have taken steps to address the violations contained in the Warning Letter.” But both products are still for sale, even now, a Nashville Vapor salesperson confirmed to STAT.
  • Might not be worth it to bring vape shops to court
    • Scheineson argued that the FDA’s approach toward vape shops has been “unnecessarily overkill” and said that the FDA may have trouble convincing the Department of Justice to take small vape shops to federal court. If the agency lost its case, moreover, it might significantly set back its regulation of vaping writ large.
    • “I can’t believe … anybody is going to want to use the full resources of the Justice Department to go after Vape Store Number One in Cody, Wyoming,” said Scheineson, who was previously an associate commissioner at the FDA.

 

Teen was in the fight for her life after vaping a cartridge a day I Nightline

  • Teens are getting sick
    • 00:35: Teen injured from vaping
    • 01:10: 6 deaths from vaping
    • 02:30: She stopped dancing because of it
  • Vaping seems safe but it’s not
    • 01:25: Vaping seems like the safer choice but it's not
  • Marketing to kids
    • 04:10: Vapes look like candy wrappers
    • 06:35: FDA sent a warning letter to Juul
    • 07:00: They market it to children
  • Vaping causes inflammation
    • 05:10: Explaining that vaping is inhaling heated oil and causes inflammation
    • 05:35: Kid coughing from vaping

 

How JUUL Hooked Kids & Ignited A Public Health Crisis | TIME

  • Juul looks cool
    • 00:35: Juul is a cool looking item, it looks like sleek and smells good
  • Juul getting trouble
    • 01:00: Juul IS big tobacco , no I don't agree with that.
    • 01:20: Juul said their cigarettes were safe so kids started smoking them
    • 01:50: A Juul rep told a kid that it's safe.
    • 03:35: Juul was marketing themselves as safer then cigarettes but they got in trouble for it.
    • 04:38: For every adult who quits smoking there's 80 kids who start smoking.

 

The Rise And Fall Of Juul | Rise And Fall

  • Juul is popular with teens
    • 00:10: Juuling became a verb
    • 00:20: It was never their intention to make teenagers addicted, but they did.
    • 00:40: Juul is now facing huge lawsuits for addicting kids
    • 01:00: It looks like a flash drive, so parents wouldn't know it was an e-cigarette
    • 03:35: Kids would vape in the bathroom
  • Juul exploded
    • 02:00: By 2017, they had a huge portion of the market (1/3)
  • They didn’t have warning labels
    • 02:30: Originally there was no warning label on the box and no warning of nicotine
    • 02:40: "no one knew what 5% nicotine meant"
    • 02:45: One pod has the same amount of nicotine as a pack of cigarettes.
  • Juul got in trouble
    • 03:55: American pediatrics sued FDA because they weren't taking action against vaping.
    • 04:00: FDA allowed the products to stay on market until 2022
    • 04:40: FDA let the vaping industry be unregulated for years. It's mostly FDA's fault
    • 05:20 In response Juul got rid of their flavors and shut down social media.
    • 06:50: Juul was selling nicotine addiction
  • Juul accepted money from big tobacco
    • 05:50: Altria a big tobacco company invested into Juul and owned a 35% stake in the company. Earlier the owners said they wanted to take big tobacco down, but now, they're accepting money from them?
  • EVALI epidemic
    • 07:50: After awhile, ids started getting EVALI, lung injury. It was caused by bootleg vaping products
    • 09:00: School boards started to sue Juul, they removed mint pods.
  • Lawsuits
    • 09:25: Lady explaining all the money they had to pay from lawsuits
  • They’re still on the market
    • 10:00: FDA still didn't take Juul off the market, they judge tobacco products on the risks vs. benefits on the population as a whole.
    • 10:55: Puff bars use synthetic nicotine so they are not ruled under FDA

 

Is Vaping Better Than Smoking Cigarettes?

  • Vaping can damage lungs
    • 02:40: Vitamin E is linked to EVALI outbreak
    • 04:10: A teen got sick because he vaped and developed a lung issue
    • 05:40: They're sucking in chemicals all day long!



How Juul Hooked a Generation on Nicotine

  • Juul executives intended to make a product to replace cigarettes
    • Juul’s mission has always been to give adult smokers a safer alternative to cigarettes, which play a role in the deaths of 480,000 people in the United States each year.
    • But in reality, the company was never just about helping adult smokers, according to interviews with former executives, employees and investors, along with reviews of legal filings and social media archives.
  • They purposely targeted young people
    • Juul’s remarkable rise to resurrect and dominate the e-cigarette business came after it began targeting consumers in their 20s and early 30s, a generation with historically low smoking rates, in a furious effort to reward investors and capture market share before the government tightened regulations on vaping.
    • As recently as 2017, as evidence grew that high school students were flocking to its sleek devices and flavored nicotine pods, the company refused to sign a pledge not to market to teenagers as part of a lawsuit settlement. It wasn’t until the summer of 2018, when the Food and Drug Administration required it to do so, that the company put a nicotine warning label on its packaging.
  • Atria bought into Juul
    • Though some former employees recalled Mr. Monsees wearing a T-shirt at the office that used an expletive to refer to Big Tobacco, the start-up’s early pitches to potential investors listed selling the business to a big tobacco company as one of the potential ways to cash out. (Last December, the tobacco giant Altria paid $12.8 billion for a 35 percent stake in the company.)
  • Investors in Juul didn’t want it to be regulated by the FDA
    • “They had yet to see the fruits of their investment, given what the opportunity was, and it was unclear for how long vaping was going to be lightly regulated,” said Scott Dunlap, the chief operating officer at the time. “They were excited and pushing hard.”
  • At first the product didn’t work well
    • “I was in that first meeting where you tell the board, ‘We aren’t going to hit the numbers. There are issues; there are problems in the supply chain.’ Not a lot of good news,” said Mr. Dunlap, who said he had advised the company to slow down and take the time needed to fix the problems. He was fired the next day.
  • Vapes exploded in 2016
    • From 2016 to 2018, the years Juul’s growth became astronomical, the number of adult nonsmokers who began using e-cigarettes doubled in the United States, according to an analysis of federal survey data by researchers at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. The study estimates that six million adults were introduced to nicotine via e-cigarettes.
  • Many teenagers vape now
    • During that time, millions of high school and middle school students began vaping, according to federal health surveys. More than five million youths — one in four American high school students and one in 10 middle school students — now vape, the Centers for Disease Control and Prevention and the Food and Drug Administration said in a joint report this summer. Nicotine is a highly addictive drug that impedes the developing brain, and many teenagers have struggled to quit.
    • From the beginning, there was plenty of evidence of teenage use on social media that should have been apparent to a company that had made social media the core of its marketing strategy. A sampling of tweets from Juul’s first 18 months of sales showed that juuling had quickly become a fad among high school students, long before the company acknowledged that there was a problem.
  • Juul had to stop selling flavors
    • The company says it is refocusing on its core mission. It has recently taken steps to keep its products away from teenagers, including stopping sales of most of its flavors; halting all broadcast, print and digital advertising; and offering $100 million in incentives for retailers to adopt a new electronic age-verification system intended to curb illegal sales to minors. 
  • How Juul was started
    • The story of Juul began more than a decade ago when two smokers, Mr. Monsees and Adam Bowen, became friends over cigarette breaks as graduate students in design at Stanford. During those chats, they came up with an idea for their final thesis, a design for an e-cigarette that would give smokers the nicotine they craved but without the cancer-causing  substances that come from burning tobacco. They called it Ploom, and two years later, in 2007, they started a company by the same name.
    • Ralph Eschenbach, an early investor through the firm Sand Hill Angels, recalled Ploom’s pitch as being fairly simple: “They said they wanted to build a cigarette that would be a lot less dangerous to smokers and could be enjoyable.”
    • But, Mr. Eschenbach said, there was a major hurdle in going after that demographic: F.D.A. restrictions prevented Ploom from claiming its product was safer than cigarettes.
    • When it was released in 2010, the Ploom Model One Vaporizer was shaped like an oversize pen. After a couple of years, it became clear that it wasn’t going to catch on. The biggest complaint? Not enough nicotine.
    • Kurt Sonderegger, who was Ploom’s head of marketing, would tape two of the devices together to try to get a satisfying hit, he said, but “I still needed to go out and smoke a cigarette.”
  • Targeting young people
    • So the company was eying another potential market as well, he said: young millennials who were occasional smokers and might be drawn to a luxe, sleekly-designed tech product that they could carry while bar hopping on a Saturday night.
  • They attracted a lot of investors
    • Other investors jumped on board, most notably Nicholas J. Pritzker, a member of the wealthy Chicago family that once owned the chewing tobacco giant Conwood before it was sold to Reynolds American. Mr. Pritzker had focused on the family’s holdings in real estate and the Hyatt hotel chain. Calls and emails to Mr. Pritzker’s investment firm were not returned.
  • They made a cigarette with higher nicotine content which was the Juul
    • But the company wasn’t abandoning e-cigarettes. On the contrary, it had a breakthrough. It had discovered a way to substantially increase the nicotine levels in a new product, named Juul.
    • It was this breakthrough  that would make the Juul so addictive to teenagers and people who had never smoked.
    • But just before the debut, in an interview published by The Verge in April 2015, Ari Atkins, an engineer who had worked on the team developing the Juul, said: “We don’t think a lot about addiction here because we’re not trying to design a cessation product at all.”
  • The hit was smooth
    • What made the Juul a game-changer in the e-cigarette industry was not just the cool design, which immediately drew comparisons to the iPhone. It was the power and smoothness of its nicotine hit.
  • They use nicotine salts
    • Nicotine salts are not exactly like the crystalline salt in a shaker on the dinner table. In chemistry, a “salt” is the substance produced from the reaction of an acid with a base. Nicotine salts exist naturally in tobacco, which means they are in all cigarettes.
  • Vapes used to use freebase nicotine which was harsh
    • But e-cigarettes at the time were using freebase nicotine, which is extracted from tobacco. The problem with freebase nicotine liquid is that it has a high alkalinity, which makes it harsh for consumers. Many smokers who tried e-cigarettes wound up with sore throats or coughs.
    • For manufacturers, that harshness increased with higher nicotine levels, so most e-cigarettes had only 1 or 2 percent nicotine. A few came in at 3 percent.
  • Juul used a different type of nicotine
    • Dr. Xing and other researchers at Pax were able to develop a formulation that allowed the company’s Juul pods to have a nicotine level of 5 percent, the equivalent of a pack of cigarettes. They had worked through different formulations before landing on one that combined freebase nicotine with benzoic acid (the patent covers a range of acids) that set off a chemical reaction, producing a nicotine salt liquid that reduced the harshness and allowed a higher rate of nicotine.
    • Mr. Dunlap, the chief marketing officer at the time, saw the immense promise. “When I first tried the Juul prototype, the nicotine hit was immediate, within seconds. No e-cig had ever come close to this,” he said. “The design was also unique — the shape, the glowing light, the crackling sound, the thick vapor. It was a multisensory experience. This was the first vaping product that actually had a shot at switching an existing smoker.”
  • It’s not a cigarette
    • The nicotine experience was the key to attracting smokers to any e-cigarette, but mention of nicotine was only in tiny, hard-to-read letters in the print ads for Juul’s initial marketing campaign.
    • In June of 2015, the campaign, called Vaporized, introduced the Juul with glitzy parties and events that stretched from San Francisco to Miami and New York, and ads and social media posts featuring young women in midriff-baring tops holding the sleek metal device.
  • They made their marketing targeted to youths
    • Even some employees were confused. Three members of the company’s sales force recalled being puzzled: If this was a product targeting smokers, why not market where the smokers were, say, NASCAR races, which had long been sponsored by tobacco companies? Why was the campaign so youthful?
  • How they marketed Juul
    • The ads for Juul showed up in Vice magazine, at pop-up “Juul Bars” at concerts that offered free samples of the product, on a bright billboard display that loomed over Times Square, and in a social media blitz. A lawsuit filed this month by the state of California against the company said that Juul directed “brand ambassadors” to look for “people who fit the JUUL demographic” such as “smokers, cool kids, fun people, etc.”
    • The company began hiring consultants to identify social media influencers with large followings on Instagram and Twitter to promote Juul. It pushed hashtags like #juul and #vaporized that the influencers used while showing images of themselves or other young people doing tricks with the device.
    • Mr. Dunlap, the chief operating officer at the time, noticed strikingly young users right away, in the wave of social media posts that followed the marketing events.
    • “There were hundreds of activation events, and it was in seeing the photos and social usage that followed that I would catch myself saying, ‘Wow, they look really young’,” he said. “But you don’t really know. It’s social media after all, where everyone is their younger, idealized selves. All you know is that you are seeing the early signs of a viral brand taking off.”
    • Two former executives, one from marketing and one from sales, said in interviews that the thinking inside the company was that by showing young and hip people using Juul, they would also draw in older smokers who imagined themselves as, well, young and hip.
  • It wasn’t labeled with warnings
    • Ms. Legacki said she has now scaled back her vaping but has not been able to quit. “If I knew it had nicotine at all, I wouldn’t have done it,” she said. “Now I’m so reliant on something I had no intention of doing. I knew what cigarettes do. This Juul was new and nobody knew what the Juul did.”
  • Kids were buying them illegally
    • Employees were also noticing orders made with clearly fake IDs. In 2017, orders were coming in weekly that all used an Arizona driver’s license for a man from Phoenix named Jelani Sample, according to an employee brought in to upgrade the age verification system. (It was actually a sample of the new driver’s license the state had posted online.)
  • They planned to make party vapes but they were never made
    • But the company continued to push its presence on social media, and in 2017, with sales soaring, the company and Mr. Bowen, the co-founder, filed a patent for a vaping device with a feature that seemed aimed at younger users. It was a gaming mode, so people could play Simon Says or Cat and Mouse on the device. It also had a “party” mode with lights and music clips. (It was never made, however.)
  • Juul contained formaldehyde -  lawsuit
    • That same year the company was in talks to settle a lawsuit brought by the Center for Environmental Health, a nonprofit in California. The group had tested e-cigarettes and nicotine liquids made by Juul and over a dozen other companies and found levels of formaldehyde, a carcinogen created when e-cigarettes containing certain chemicals are heated, that exceeded the California limit. The organization had sued the manufacturers to force them to lower formaldehyde levels, and to add a warning label noting the presence of a cancer-causing ingredient.
    • But in settling the cases, the environmental group saw an opportunity to do something more. “We wanted to go beyond just the cancer warning,” its lawyer, Mark Todzo, said. “At the time, there were reports coming out about the teen vaping rates that were just starting to be reported on.”
    • Mr. Todzo said the group added a provision into the settlement to require the e-cigarette companies to agree not to market to youths. Documents show that it was signed by EonSmoke, Vapor4Life, International Vapor Group and others — but not by Juul.
    • Juul declined to sign and opted instead to pay an additional penalty, based on its sales for 2015 — just $2,500.
    • Mr. Raffel, the Juul spokesman, did not dispute the account, but said the company had no further comment.
    • Finally, last month, Juul signed.
  • They were ordered to remove their flavored pods from the market
    • “They just refused to do it,” said Mr. Woods, who dropped out of the advisory group after the initial call, convinced that the company was insincere. “I said on the call, ‘I would sue you.’”
    • Mr. Woods said the Juul C.E.O., Mr. Burns, took the position “that they were not marketing to minors, and so the flavoring wasn’t an issue.” Mr. Burns declined to comment on the phone call.
    • Mr. Burns’s recalcitrance in the face of growing pressure would soon be on display again in the company’s weekly executive meeting in September 2018,  after the F.D.A. seized thousands of pages of documents from the company’s San Francisco headquarters, a former executive said.
    • “Kevin Burns said, ‘Do not give me anything in writing if it is sensitive, anything the F.D.A. could get,’” recalled the former executive, who was at the meeting but asked not to be identified for fear of retribution. “He said, ‘Pick up the phone and call me if you have to.’”
  • Everyone is suing them
    • Now Juul is facing an ever growing pile of lawsuits from parents, school districts, counties and states, including two new ones filed this  month by California and New York. In addition to the F.D.A., the Federal Trade Commission, the United States attorney’s office in Northern California and several states are investigating the company.
    • And it is still waiting for federal health officials to completely clear its devices and nicotine pods from the mysterious vaping-related illness that emerged this summer, making almost 2,300 people seriously ill and killing 47 others. Earlier this month, the Centers for Disease Control and Prevention said that the likely culprit is THC vaping liquids, which Juul does not sell, that include vitamin E acetate, but cautioned that health investigators had not exonerated nicotine products.
    • All of this means that the F.D.A. is likely to make it very challenging for Juul to obtain the necessary clearance to stay on the market, according to two former F.D.A. commissioners: David Kessler, who served in the George H.W. Bush and Clinton administrations; and Scott Gottlieb, who ran the agency for President Trump until resigning this spring.
    • Juul’s application is due in May, and the F.D.A. must decide whether the products are appropriate for the protection of public health. The agency will weigh the number of people likely to become addicted to nicotine via Juul, against the number who might use it to quit combustible cigarettes, and will also assess the safety of the products.
  • Atria bailed them out
    • It would take 20 months to work out, but on Dec. 20 of last year, Altria announced it would pay $12.8 billion in cash for a 35 percent stake in Juul. Filings with the Securities and Exchange Commission showed that the vast majority of the cash went into executives and investors’ pockets. Less than $1 billion was required to stay on the company’s books.
    • Under the terms of the deal, Altria said it would use its vast distribution channels to sell Juul products and, after four years, Altria would be allowed to make a takeover offer for Juul Labs
    • Some employees were unsettled by the fact that they were now in business with Big Tobacco. And regulators? They were irate.
    • The F.D.A. was blindsided by Juul’s deal with Altria, and it further strained the relationship between the agency, including its commissioner, Dr. Gottlieb, and both companies.
  • The FDA pushed forward their deadline to get Juul off the market
    • The F.D.A. had initially been supportive of e-cigarettes, and Dr. Gottlieb had served on the board of Kure, a chain of vaping lounges, before he was tapped to run the agency. In July 2017, a few months after taking office, Dr. Gottlieb made a much criticized decision to push back by four years the deadline for Juul and other e-cigarette companies to submit applications to stay on the market.
  • Atria buying out Juul angered FDA
    • Juul contended it had a virtuous health mission, but by fall of 2018, the F.D.A. was no longer buying it. In October, Altria had agreed to stop selling its own e-cigarette products, after acknowledging that they were driving the youth vaping problem. The notion that Altria would now help Juul expand its market infuriated Dr. Gottlieb.
    • He summoned executives from Juul and Altria to his office in March of this year, for what several people who were there (and not authorized to speak publicly on the matter) described as a tense, unpleasant meeting with him, his chief of staff, Lauren Silvis, and the head of the agency’s tobacco division, Mitchell Zeller. When news about their difficult meeting leaked out, Altria’s stock fell 2.5 percent.
  • Juul tried to lobby the gov
    • According to several people present, Dr. Gottlieb condemned Juul’s lobbying of Congress and the White House. “We have taken your meetings, returned your calls and I had personally met with you more times than I met with any other regulated company, and yet you still tried to go around us to the Hill and White House and undermine our public health efforts,” he said angrily, according to three people who were there. “I was trying to curb the illegal use by kids of your product and you are fighting me on it.”

 

How Big Tobacco made cigarettes more addictive

 

E-cigarettes expose users to toxic metals such as arsenic, lead

  • Exposes you to heavy metals
  • Vitamin E causing EVALI
    • An outbreak of lung injuries associated with e-cigarette use, or vaping, that began in 2019 led to 2,807 hospitalizations and 68 deaths in less than a year. Even though the outbreak was eventually attributed to a chemical called vitamin E acetate that was added to some vaping devices, Rule and other experts believe it demonstrated that e-cigarettes are not as safe as previously believed.
  • How vaping works
    • Although e-cigarettes come in many shapes and sizes, they are all composed of three basic parts. Those include a battery, a coil, and a liquid that contains nicotine and other components, noted Rule. When heated, the liquid becomes an aerosol, or plume, that is inhaled by the user.
  • Liquid comes into contact with a metal coil
    • Since 2018, Rule has led the NIEHS-funded Exposure to Metals from E-Cigarettes (EMIT) Study to do just that. She chose to focus on metals because the vaping liquid comes into direct contact with the coil, which typically contains metals and metal alloys that have been linked to negative health effects.
    • “We know from many studies that both nickel and chromium are inhalation carcinogens,” said Rule. “These compounds are going straight into the lungs.”
    • Through the EMIT study, Rule’s team has analyzed metal concentrations in the e-liquid before it is in contact with the heating coil, and in the aerosol generated afterwards. They were surprised to find toxic metals, such as arsenic and lead, in the liquid even before it came into contact with the metallic coil.
    • The researchers have also measured the levels of metals in blood, urine, saliva, and exhaled breath condensate of 250 e-cigarette smokers, conventional cigarette smokers, and non-smokers. They have found significant differences between e-cigarette smokers and non-smokers, although determining what that means in terms of potential health effects will require more research, according to Rule.
    • In addition to various doses of nicotine and heavy metals, vaping liquid can also contain flavorants such as ethyl maltol, an artificial sweetener that tastes like cotton candy. Because ethyl maltol has long been known to help transport heavy metals into cells, Rule wondered whether the substance might enhance the potential toxicity of e-cigarette preparations. Together with her colleague Joseph Bressler, Ph.D., she showed that co-exposure to ethyl maltol and copper caused lung epithelial cells — which line the surface of the lungs — to die off.

 

E-Cigarette Ingredients

  • Vape juice ingredients
    • E-cigarettes like Juul contain cartridges or pods of e-liquid made with water, nicotine, a propylene glycol or vegetable glycerin base and flavorings. But with thousands of brands available and no set FDA standards, it can be difficult to determine exactly what is in a vape’s e-liquid.
    • It’s difficult to determine what is in the thousands of different e-liquids, also called e-juice or vape juice, sold for e-cigarettes. Part of that is because the U.S. Food and Drug Administration hasn’t reviewed ingredients or set standards. There are many brands and flavors with many different ingredients.
    • According to the FDA’s page, last updated in June 2022, “These products use an ‘e-liquid’ that usually contains nicotine derived from tobacco, as well as flavorings, propylene glycol, vegetable glycerin, and other ingredients. The liquid is heated to create an aerosol that the user inhales.”
  • Ingredients may be more toxic when inhaled
    • Base ingredients such as propylene glycol and vegetable glycerin may be non-toxic when ingested orally, but researchers aren’t sure how safe they are when vaporized and inhaled.
    • Benzene: A compound found in car exhaust. Long-term exposure may cause blood problems and cancer of blood-forming organs, such as leukemia.
    • Acrolein: A weed killer that can cause irreversible lung damage.
    • Acetaldehyde and formaldehyde: These chemicals are known to cause cancer.
    • Cadmium: Toxic metal that increases the risk of breathing problems such as chronic obstructive lung disease and emphysema. It’s also found in traditional cigarettes.
    • Diacetyl: Chemical compound used to give food a buttery flavor. Studies link inhaling it to lung disease called bronchiolitis obliterans, also known as “popcorn lung.”
    • Diethylene glycol: Clear odorless liquid with a sweet taste typically found in industrial products such as antifreeze. It’s used as a base in e-liquids. It’s toxic and is linked to lung disease.
    • Nickel, tin, lead and other heavy metals: Heavy metal toxicity may damage functioning of lungs, brain, liver, kidneys and other organs.
    • Nicotine: A highly addictive chemical that can affect the heart and breathing.
    • Propylene glycol: A clear, odorless liquid that’s used as antifreeze and a food addictive. It’s used as a base in e-liquids. It turns to vapor when heated but may produce propylene oxide, a known carcinogen.
  • Nicotine was used as insecticide
    • Nicotine is a highly addictive chemical that comes from the tobacco plant. At one time it was used as an insecticide in the United States. It’s found in most tobacco products, including e-cigarettes.
    • It only takes about 10 seconds for nicotine to reach the brain after it’s inhaled. Once in the brain, it activates the pleasure centers, giving people feelings of pleasure and relaxation. Nicotine addiction keeps people vaping.
    • The amount of nicotine in each e-cigarette varies by brand. When it was first released, Juul offered pods containing five percent nicotine, according to Truth Initiative. That’s the equivalent of one pack of cigarettes per pod.
  • Nicotine side effects
    • Abnormal heart rhythms
    • Headache
    • Increased heart rate
    • Muscle twitching
    • Rapid breathing
    • Seizures
    • Stomach upset
    • Tremor
  • You’re heating chemicals so that can make them more toxic
    • Studies have found more than a hundred compounds in e-cigarette liquids. Even more compounds are created when chemicals are heated and vaporized, according to a 2018 review by the National Academies of Sciences, Engineering and Medicine.
    • A 2018 study in Nicotine & Tobacco Research found these reactions between flavorings and propylene glycol, which is used to make the vapor, can expose users to the same potential risks of tobacco cigarettes.
    • Heating e-liquids can increase the concentration of toxic chemicals in aerosols.
    • “Even in the absence of heating and combustion, chemical reactions are occurring in e-cigarette liquids and the resulting compounds could be harmful to the user’s airways,” researcher Hanno Erythropel told the American Journal of Managed Care.
    • When heated, chemicals in vape juice can become more toxic. Higher-powered devices can increase levels of toxic chemicals in vapor by aerosolizing ingredients at higher temperatures.
    • For example, people can vape more than 200 times the level of formaldehyde, acetone and acetaldehyde by increasing the voltage from 3.2 to 4.8. Levels of formaldehyde from high-voltage e-cigarettes were almost the same as traditional cigarette smoke, according to the National Academies of Sciences, Engineering and Medicine.
  • Formaldehyde
    • Another 2018 study, this one in the journal Scientific Reports, found that chemicals in vape fluid can combine to create various forms of formaldehyde, a naturally occurring chemical that has been linked to certain types of cancer in people with repeated exposure.
    • Researchers found that under normal vaping conditions, gaseous formaldehyde was produced at levels above those considered safe by the Occupational Safety and Health Administration.
  • Toxic flavorings
    • There are more than 7,000 vape juice flavors available to e-cigarette users, according to the National Academies of Sciences, Engineering, and Medicine. Some of these are considered safe in typical food products when eaten, but may be harmful when inhaled in aerosol form.
    • A 2015 study conducted by Harvard University researchers found that many different flavorings added to e-liquids in e-cigarettes contain chemicals that may be harmful to users’ long-term health.
    • Some flavors included in the study were: Classic, Menthol, Cherry Crush, Java Jolt, Pina Colada, Vanilla Bean, Bad Apple, Iced Berry, Banana, Pomegranate, Peach Pit, Watermelon, CooCoo Coconut, Pineapple Punch, Carmel Popcorn, Bubble Gum, Cotton Candy and Tutti Frutti.
    • Results showed that at least one of the three common flavoring chemicals — diacetyl, 2,3 pentanedione or acetoin — was present in 47 of the 51 flavors tested.
    • Diacetyl was found in 39 of 51 flavors tested.
    • 2,3-pentanedione was found in 23 of the 51 flavors.
    • Acetoin was found in 46 of the 51 flavors.
    • Diacetyl and 2,3-pentanedione were present simultaneously in 21 flavors tested.
    • 2,3-pentanedione and acetoin were found simultaneously in 22 flavors.
  • Mislabeling
    • The University of North Dakota researchers collected 94 e-liquid samples. More than half were mislabeled by at least 10 percent.
    • Seventeen percent had more nicotine than listed on the label, and one of those samples contained 172 percent more nicotine than was listed on the label.

Jake Tran

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