On December 20, 2019, the government raised the federal minimum age of sale of tobacco products, including e-cigarettes, from 18 to 21 years, according to the FDA. This age limit increase came on the heels of a summer that ended with multiple deaths reported as being caused by popular e-cigarettes and vaping products.

In an email, Brian Deloach, Ph.D. and medical director of the health center at Georgia Southern, said that e-cigarettes were developed as an electronic nicotine delivery system that vaporizes liquid containing nicotine rather than burning tobacco.

Deloach added that, originally, they were purported by manufacturers as a “safe alternative to traditional cigarette,” quoting the CDC.

Eric Greenhaw, a senior English major at GS who has worked as a salesperson for A Smokin’ Place since last May, said he believes vaping is popular because vapes taste better than the traditional cigarette and because it’s for people who want to stop smoking.

“But then you have the adverse of, you know, high schoolers getting started with this and with JUULs,” Greenhaw said.

JUULs are a popular brand of e-cigarettes that are shaped like a USB drive, as described by the CDC.

However, Deloach also said, “They are regulated by the FDA, but they are not approved by the FDA as a quit smoking aid.”

Medical Dangers

“The use of e-cigarettes and vaping products is unsafe for all ages,” Deloach said. “Almost all e-cigarettes and vapor devices, including JUUL, are used to inhale a vapor that almost always contains nicotine along with other chemicals and other flavoring agents.”

Deloach added that nicotine is addictive and has been shown to harm the developing brain in children, teens and young adults, as the brain keeps developing until age 25. 

“Using nicotine, in any form, can harm the parts of the brain that control attention, learning, mood and impulse control,” said Deloach. “Using nicotine in these age groups may also increase the risk of using tobacco and other addictive substances.”  

You don’t have to be the one vaping to be affected, either.

“Some of the other ingredients in substances used in JUUL and other vaping devices could also harm the lungs—not only to those using them but also to those exposed to the vapors,” said Deloach. “Also, there is a risk of explosion and burns associated with the use of these devices.”  

The Age Limit Increase

Greenhaw said it’s an everyday thing for people to come in to buy vape-related products, and they are one of their most sold items on a daily basis. While a good majority of the buyers are under 25, Greenhaw added that a good amount of those he does help are older people as well.

On the subject of the recent raising of the age limit to buy e-cigarettes, Greenhaw said it has put a lot of people in a really awkward position because there’s no grandfather clause at the moment. This means that the people who are under the new age limit but who are already using vaping products can no longer legally get a product they are used to.

“They’re kind of in a weird spot of having to either get someone to buy it for them or quit,” Greenhaw said.

However, Greenhaw said he believes this will stop high schoolers from vaping as much because he didn’t know anybody 21 or older when he was in high school. 

“So I feel like there is some rationale to that,” Greenhaw said.

Greenhaw wasn’t working the day they officially announced the age limit increase and made the smoke shop start following the procedures, but he said a lot of people were very upset.

“But one of my coworkers…it was so bad for him. He got cussed out by people. People were thinking that it was his fault, I guess,” Greenhaw said. “Yeah, a lot of very upset people, even people that were 21.”

While the age limit increase definitely had an impact on sales, Greenhaw said it’s since had time to fizzle out and it’s kind of rebounded.

“Now, I suspect that sales are going to get better, just kind of as people adjust, so I’m not really too worried about it,” Greenhaw said.

On the Recent Deaths

“As of October 15, 2019 there have been 1,479 lung injury cases associated with the use of e-cigarettes and vaping, and 33 deaths have been reported in 24 states,” Deloach said. “In Georgia, to date 21 cases of vaping associated lung injury have been reported to DPH [Department of Public Health], including 2 deaths, and 15 additional possible cases are being investigated by DPH.”

This lung illness is known as e-cigarette, or vaping, product use associated lung injury (EVALI). No one compound or ingredient has emerged as the cause of these illnesses to date, but many different substances and product sources are still under investigation. 

However, according to Deloach, most cases that have sent the e-cigarette fluid to the FDA for testing have tested positive for THC. The CDC describes THC or tetrahydrocannabinol as the psychoactive mind-altering compound of marijuana that produces the “high.”

79% of the cases were in patients under the age of 35, and the median age has been 23, according to the CDC. 

In addition, Deloach said there have been reports of poisoning in children and adults who swallow, breathe or absorb e-cigarette liquid through their skin and/or eyes.

The CDC says case reporting shows there was a sharp rise in symptoms or cases of EVALI in August 2019, a peak in September 2019 and a gradual, but persistent decline since then. The CDC says this decline may be related to increased public awareness of the risk of THC-containing vaping products, the removal of vitamin E acetate from some products and law enforcement actions related to illicit products.

Mixing Vapes with Other Substances

Since the rise in e-cigarette popularity, people have added other substances than nicotine to the liquid, such as THC and CBD-containing products, according to Deloach.

Deloach said particularly unsafe practices include using e-cig/vape products that contain THC, buying e-cig/vape products off the street and modifying/adding substances to e-cig/vape products.

Greenhaw said, if you really look at the articles that have been put out since last summer since the recent deaths, they talk about not even nicotine vaping but the THC cartridges that were really popular. 

Something that bothered Greenhaw about the articles that claimed vapes were killing people was that they would say something about the vitamin E oil and the THC cartridges but would show a picture of a JUUL or a picture of a nicotine vape.

“And those are two entirely separate, different things,” Greenhaw said. “Vaping cannabis is not vaping nicotine. There’s–it’s two entirely different processes that go into it. And, for one, I am glad that they did expose kind of this underground vitamin E thing.”

Vitamin E acetate is an additive in some THC-containing e-cigarette or vaping products and is used to dilute the THC oil. According to the CDC, while vitamin E acetate is in certain foods and does not cause harm when ingested orally or applied to the skin, previous research suggests that when inhaled, this additive may interfere with normal lung functioning.

Greenhaw said a lot of the lung illness cases were from just people using vitamin E oil.

In fact, in an interview for a January 2020 article with Advisory Board, the CDC’s principal deputy director, Anne Schuchat, said that they had determined that the majority of cases of EVALI “can be attributed to exposure to [tetrahydrocannabinol (THC)]-containing vaping products [with] vitamin E acetate.” 

CDC says that laboratory data show that vitamin E acetate is strongly linked to the EVALI outbreak. During a recent study reported by The New England Journal of Medicine, researchers analyzed fluid samples collected from the lungs from EVALI patients. They found vitamin E acetate in 48 of the 51 EVALI patients but not in the samples from the healthy comparison group.

https://www.npr.org/sections/health-shots/2019/12/20/790154919/cdc-confirms-a-thc-contaminant-vitamin-e-acetate-the-culprit-in-most-vaping-deat

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

However, the article also stated that she said that the CDC hadn’t ruled out other potential culprits, either.

“So, even some of the dispensaries out in legal states were cutting it with vitamin E still or there was just a black market thing,” Greenhaw said.

Deloach said e-cigarettes obtained off the street or from informal sources are not regulated by FDA, so there is no way to know what has been added to the fluid.

“Additionally, the devices may be more prone to explode and/or cause burns,” Deloach said.

Greenhaw said if you’ve ever seen vitamin E oil in a container, it’s something that is kind of amber, a little bit thick.

“So, what vitamin E does whenever you inhale it–which, don’t inhale vitamin E–it will coat your lungs and basically your lungs have no way to break it down,” Greenhaw said. “And thus you get these pneumonia symptoms from–imagine a really, really bad case of pneumonia symptoms that comes with usually some other symptoms.”

In order to explain these cases more, Greenhaw broke down how JUUL uses a formula. 

“They take the plant …they get the nicotine isolated into a solution that is also liquid. They mix it in with juice that’s flavored. And that hits the shelf, you put it into your vape. Long story short: JUUL.”

However, there is another formula that JUUL also uses: nicotine salts.

Greenhaw said what JUUL started doing a few years ago was they would take the salt from the tobacco plant and they would make that into a nicotine solution. 

“Now how that differs from what I called the regular nicotine solution comparatively, it’s a lot more potent than a regular nicotine solution,” Greenhaw said. “That means that the effects from it–what they call the nicotine buzz–it’s a very fast onset.”

According to the CDC, nicotine salts allow particularly high levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally been used in tobacco products, including e-cigarettes.

Greenhaw said they released JUULs with this formula in two strengths: 3% and 5% blend. He also said that nobody needs that much nicotine in a sitting and that in Europe, for example, the highest strength they go to is 2.4%.

JUULSalts are cut with benzoic acid. Greenhaw said they cut it with acid to make the hit smoother on your throat because that much nicotine is very rough on the throat. Greenhaw said he thinks that may have had another dealing to do with these cases of lung illness that came from nicotine vaping.

“Now I don’t really touch the nicotine salts just because I feel like even something like 2.4% is just too much for me,” said Greenhaw.

The CDC says, according to the manufacturer, a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes.

Greenhaw said that, after he quit using that much nicotine at the time, he felt a lot better.

Greenhaw said he’s probably even smoked a few of these vapes cut with vitamin E under the thought there were actual legitimate cartridges. 

Greenhaw said it’s interesting to him how we treat JUUL here versus Europe. While in London last December, he noted the billboards on vaping. He would walk down the street and see billboard ads and they would be someone giving a testimonial about how it saved their life or the benefits. 

Greenhaw said he feels like if we didn’t maybe do something as high as 5% or even 3%, maybe it would work.

How to Be Safe

“Since the vaping-related outbreak has become publicized, we have had students come in with questions about vaping who are concerned that they have damaged their lungs,” Deloach said. “While we have not seen any cases associated with the outbreak, it is provided an excellent opportunity to inform our patients about the risks of vaping and e-cigarettes.”

Here are guidelines and information provided by The Department of Public Health.

In addition, you can stay aware of some of the symptoms that vaping may be harming your body.

According to Deloach, here are some red flags:

• Cough, shortness of breath or chest pain
• Nausea, vomiting, abdominal pain or diarrhea

“Symptoms may develop over a few days or over several weeks,” Deloach said.

But what can those who vape do to be healthier? Deloach said stop vaping all-together.

“For assistance with stopping use of nicotine and other addictive substances, persons should follow up with their primary care provider to discuss options for assistance with quitting,” Deloach said.

This story was originally written for the Spring 2020 edition of Relflector Magazine