We Still Know Little About the Harms…


I recently presented a clinical scenario about a patient of mine, a young man, who vapes regularly, and asked for your critique on how I counseled my patient on health risks associated with e-cigarettes.

I appreciate the thoughtful and passionate responses to the case of Eusebio. Cogent points were presented, but the disparity of opinion regarding e-cigarettes demonstrates that we still have a long way to go to truly understand the balance of benefits and harms of these devices.

Several comments referred to acute illnesses linked to e-cigarette use. This brought to mind the serious public health scare related to e-cigarette– or vaping-associated lung injury (EVALI). A total of 2807 cases of EVALI, including 68 deaths, were reported during 2019 to 2020, which feels like a lifetime ago. Cases of EVALI peaked in September of 2019.

EVALI was associated with vaping cartridges that were modified to include tetrahydrocannabinol. The particular compound linked to EVALI in nationwide bronchoalveolar samples was vitamin E acetate, which appears benign when consumed orally or topically but likely promotes acute lung injury.

With the advent of the COVID-19 pandemic, EVALI faded quickly from the national headlines, but the use of e-cigarettes continued. If the threat of severe, permanent lung scarring failed to scare off millions of e-cigarette users, what other public health or policy measures could be effective? Two comments suggested raising the cost of e-cigarettes to discourage use. In fact, the World Health Organization (WHO) has stated that excise taxes on tobacco are the single most effective and cost-effective means to reduce the global consumption of cigarettes. They provide a stark review of the economics of tobacco products:

  • The annual cost of direct healthcare and lost productivity because of tobacco use globally is approximately $1.4 trillion.

  • Excise taxes on tobacco products raised $361 billion across the globe in 2018.

  • Each 10% increase in the price of tobacco products through taxes reduces tobacco use by 5% in low- and middle-income countries.

The WHO makes these recommendations regarding the application of excise taxes on tobacco products:

  • The tax should be designed specifically to increase the cost of tobacco products. Taxes should therefore be responsive to inflation and economic growth.

  • Simple tax structures are preferred across tobacco products to reduce consumer incentives to downshift to cheaper tobacco products.

  • Taxes on tobacco products should be part of a more comprehensive effort to reduce use.

Finally, a point on communication. Thank you to Philani for identifying the open door to a meaningful conversation with Eusebio. This occurs precisely when he asks whether e-cigarettes are less harmful than are conventional cigarettes. On the basis of the responses of the group, we will take different pathways in sharing information about e-cigarettes. Still, I believe that two messages are very important: (1) there is much that we still do not know about e-cigarettes, particularly the risk for complications with prolonged use and (2) not using e-cigarettes or conventional cigarettes is ideal.

Thank you again for your participation in this activity!

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