Trending Clinical Topic: Vaping

Ryan Syrek


August 05, 2022

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In late June, the FDA ordered Juul Labs to stop selling electronic cigarettes and vaping products on the US market. Although the ban has been temporarily halted, the move is the latest attempt to address concerns about the e-cigarette industry, specifically when it comes to young people. From the FDA's reaction to the American Heart Association (AHA) calling for even more widespread and immediate action (see Infographic), vaping has been the focus of much recent attention, leading to this week's top trending clinical topic.

On June 23, the FDA ordered Juul to stop distributing all e-cigarette and vaping products and remove everything on the market. That included the Juul device and flavor replacement pods in the tobacco and menthol flavors. The decision came after a 2-year review of the company's request to continue selling non–fruit-flavored products, such as menthol and tobacco. The FDA determined that application "lacked sufficient evidence regarding the toxicological profile of the products to demonstrate that marketing of the products would be appropriate for the protection of the public health."

However, in early July, the FDA put that ban on hold, saying they would perform an additional review of the application. On Twitter, the FDA said they had identified "scientific issues unique to the Juul application that warrant additional review." They further explained that "[t]he stay and the agency's review does not constitute authorization to market, sell, or ship JUUL products."

Some in medicine were enthusiastic about the initial Juul ban. Estimates suggest that 11.3% of high schoolers vape, allegedly owing to marketing that depicted the products as safer than traditional cigarettes — despite findings that each 5% (nicotine-by-weight) cartridge is approximately equivalent to a pack of cigarettes. Beyond tobacco- and nicotine-related concerns, other health issues began to mount as well, with highly publicized reports of lung injuries dating back to before the pandemic.

These combined issues are what prompted the AHA to issue their recent scientific statement. The AHA points to studies in young adult vapers that show acute hemodynamic changes, including higher arterial stiffness; impaired endothelial function; and increased blood pressure, heart rate, and sympathetic tone. In the United States, no limits have been established on the concentration of nicotine allowed in e-liquids. Some devices have been shown to have nicotine levels of 59 mg/mL. The European Union limits nicotine concentration in e-liquids to no higher than 20 mg/mL, which is on par with nicotine levels in one standard (combustible) cigarette.

Reaction to the initial Juul ban in the United States spread worldwide. As Pierre Bizel, PhD, a member of the Belgian National Coalition Against Tobacco, told MediQuality, the intent of e-cigarette and vaping products is, above all, to increase the number of smokers. As he explained, "These e-cigarettes can only serve to create dependency as early as possible." Bizel explains that the introduction of these products has not reduced cigarette sales anywhere in the world. Conventional tobacco is still sold at the same rates, with the new method of delivery allowing manufacturers to profit on multiple fronts.

The public does seem to be increasingly aware that vaping isn't all it was initially advertised to be. A recent study found that adults more commonly perceive e-cigarettes as "more harmful" than traditional cigarettes. In addition, the percentage of people in the United States who exclusively used traditional cigarettes nearly doubled between 2019 and 2020 among those who perceived e-cigarettes as more harmful, jumping from 8.4% in 2019 to 16.3% in 2020. The sharp change in public perception followed media coverage of mysterious lung symptoms now classified as e-cigarette or vaping product use associated lung injuries (EVALI). These injuries were linked to vitamin E acetate, an additive to THC-containing products but not nicotine-containing products. The study found that the percentage of people who believed e-cigarettes to be more harmful than traditional cigarettes more than tripled from 6.8% in 2018 to 28.3% in 2020. Fewer people also viewed e-cigarettes as less harmful than traditional cigarettes, falling from 17.6% in 2018 to 11.4% in 2020.

As the FDA continues to perform another review of Juul's application, organizations and individuals in medicine continue to press for additional reform. This pressure, along with developments in the FDA's ban, resulted in vaping becoming the top trending clinical topic this week.

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