Exploring the science behind the vaping deaths

Every e‑cigarette sold worldwide contains nicotine, propylene glycol and vegetable glycerine. The device charges the liquid, often sweetly flavoured, into a vapour that’s inhaled. Unlike tobacco smoke which kills eight million every year globally, the lungs are spared from tar and carbon monoxide. It’s one of the reasons that Public Health England has hailed vaping as 95 per cent safer than smoking.

But across the Atlantic, a deadly vape cloud has been billowing from coast-to-coast. It started in late summer, and sparked America’s first vaping-related death. US health authorities promptly announced they were investigating 193 mystery cases of severe lung illnesses across 22 states. Symptoms varied from coughing and chest pain; to fever, vomiting and weight loss. Without consistent signs of infection, the cause was deemed to be chemical. The only thing all 193 had in common? Vaping.

Puff-for-puff, vaping was supposed to be far less deadly than smoking. So, what’s going on? ​“It’s never been an occurrence to me that vaping could be without harm,” says Dr Thomas Eissenberg, co-director of the Center for the Study of Tobacco Products, based at Virginia Commonwealth University. ​“The human lungs are meant for one thing: to deliver oxygen to the blood. When you challenge that with something that isn’t air, it struggles to function in a normal manner.”

The death toll is steadily rising. By mid-October, it had reached 33. Reports of lung injuries have mushroomed to nearly 1,500 cases. The most seriously ill have required treatment with oxygen and days on a ventilator. Some have suffered permanent damage, with researchers from the Mayo Clinic likening samples they’ve studied to chemical burns from an industrial accident. Of the 50 states, only Alaska remains untouched. In other words, it’s become a full-blown national health crisis.

Although every case stems from vaping, the cause remains unknown. One suspect, however, seems to be tetrahydrocannabinol (THC), the high-inducing chemical in marijuana. Vaping is a rapidly-growing part of the (legal) $10bn (£7.8bn) marijuana trade. But there’s a thriving black market, too. Illicit, bootleg THC cartridges are often spiked with a thickening agent called vitamin E acetate – also cited as a possible cause for the outbreak.

However, there are many patients who have only vaped nicotine. It means, ultimately, no one knows what’s causing the outbreak: whether it’s contaminated liquids, defective devices, or carcinogenic compounds. Perhaps, it’s simply vaping itself. ​“When you inhale propylene glycol and vegetable glycerin into the lungs, 200 times a day, every day, it seems unlikely there won’t be any problems,” Eissenberg says.

The recommendation from the Centers for Disease Control and Prevention, the leading US public health agency, is to ​“consider refraining from vaping nicotine products”. It’s dubbed the outbreak Evali: e‑cigarette, or vaping, product use associated lung injury. ​“There may be a lot of different nasty things in e‑cigarettes and they may cause different harms in the lungs,” the CDC’s principal deputy director Dr Anne Schuchat told reporters in October. ​“These are really serious injuries in the lung, and we don’t know how well people will recover from them, whether lung damage may be permanent.”

The numbers bear that Evali is typically a young man’s disease: more than two-thirds of patients are male, 80 per cent are under 35 and, alarmingly, 15 per cent are under 18. One Evali victim is just 13. The youngest to have died is a 17-year-old from New York. Even before the outbreak, teenage vaping was branded an ​“epidemic” by the US Surgeon General and the Food Drug Administration. According to preliminary federal reports, more than one in four high school students vaped regularly in 2019. The overwhelming majority cited the use of popular fruit and mint flavours. It’s led to the White House and even Melania Trump weighing in – to clamp down on Juul.

Juul Labs was co-founded by two ex-smokers, James Monsees and Adam Bowen. Its goal: to ​“improve the lives of the world’s one billion adult smokers by eliminating cigarettes”. Whereas vapes had previously been clunky and cumbersome, the Juul e‑cigarette is no larger than a USB stick: it’s small, sleek and cool. Its liquid pods – flavoured in the likes of mango nectar, apple orchard, and alpine berry – are exhaled in a small cloud that quickly dissipates. It’s easy to stash in your backpocket – meaning it’s easy to conceal.

Upon its 2015 launch, Juul’s ​“Vaporized” campaign featured young, sharply-dressed models grinning and posing in front of brightly-coloured motifs – more akin to a Gap commercial than an advert to convert the 20-a-day, nicotine-addicted crowd. ​“Juul was clearly oriented towards teens,” says Robert Jackler, a professor at Stanford, where Monsees and Bowen were graduates in product design. ​“It worked with ad agencies who attempted to create a lifestyle brand with a cult-like following.”

The tobacco industry has a long, dubious history of advertising. But Juul opted for a modern-day strategy. Jackler heads up Stanford Research Into the Impact of Tobacco Advertising. Its study of Juul’s marketing between 2015 and late 2018 documents the use of hashtags, social media influencers and Gen Z‑friendly sampling events – including EDM festival Nocturnal Wonderland. ​“Juul advertised on channels frequented by youth,” adds Jackler. ​“Hashtags were used to popularise it and make it go viral amongst teens.”

Did Juul’s marketing chime at all with its lofty mission statement of converting smokers? ​“No,” says Jackler. ​“In fact, it was utterly diametrically opposed to its goal. All the marketing at that time was aimed at starting young people on the pathway to nicotine addiction. While Juul, in theory, should’ve been an off-ramp for adult smokers, it instead became a heavily travelled on-ramp for nicotine-naive teenagers.”

Four years after its launch, Juul was valued at $38bn (£29.5) and boasted 70 per cent of the US vaping industry. But its success came at a cost, as it became the ultimate Gen Z lifestyle brand, with millions of American high schoolers vaping in 2018, it became a target for regulation. ​“The FDA won’t tolerate a whole generation of young people becoming addicted to nicotine,” said commissioner Scott Gottlieb. ​“The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end.”

In July, Juul’s then-CEO, Kevin Burns, apologised to parents whose children had become addicted to its vaping products. He’s since stepped down. Amid intensifying regulatory pressure, Juul shut down its Facebook and Instagram accounts in November. Its Twitter remains, though: a 2019 study found that nearly half of its followers were teens. On Instagram, meanwhile, #juul featured on 260,866 posts by November 2018. Memes still thrive. ​“The hashtags actually rocketed forward, because it was organic amongst the community – one that was heavily youth-oriented,” says Jackler. ​“If you search #juul now, it’s a viral, peer-to-peer promotion of Juul amongst kids.”

Juul was launched in the UK in summer 2018. Deborah Arnott, chief executive of Action on Smoking and Health, admits there were concerns. ​“However, regulation here is all different,” she says. ​“All TV, radio and press advertising is banned.” She cites a survey in which only one per cent of 11 – 18 year olds vaped because they thought it looked cool. ​“While young people are experimenting with vaping it’s not seen as ​‘cool’ in this country in the way it is portrayed in the US.”

However, the reality might be different. Jonathan (not his real name) is 17; he goes to school in west London. He first vaped when he was 14 and had never smoked a cigarette. ​“I remember vaping being particularly uncool for a long time in my early teens… it was only when Juul became popular in 2018 that more kids started to vape. It was almost presented as rechargeable, customisable candy. Obviously, that appeals to kids and teenagers.” The first vape Jonathan owned was a Juul. ​“I didn’t particularly like vaping at first but once I tried it over and over again, I started to like it more and more.”

Although Juul received an advertising black-out here, besides billboards featuring testimonials from ex-smokers aged 30-and-over, the damage may have already been done. ​“The way I heard about Juuling was through a combination of online advertising, social media and my mates,” recalls Jonathan.

“There’s clearly a youth culture worldwide,” says Jackler. ​“You cannot build a wall around social media. Even if your country shuts down tobacco marketing through traditional channels – print and TV – social media is internationalised.”

Over in the US, hundreds of schools have installed electronic vape detectors in their bathrooms – where kids ​“Juul” to avoid detection. It’s a similar story at Jonathan’s school. ​“Kids would Juul in the toilets during break and lunchtime,” he explains, adding that children as young as 11 would use Juul. ​“It was pretty easy if you wanted to. It also charges really quickly, fits in your pocket and looks like a USB stick – it’s portable and not suspicious.”

In an email to The Face, a Juul spokesperson said: ​“We have taken a considered approach since launching in the UK in July 2018 with a range of industry-leading youth prevention measures. We not only comply with all local regulations but aim to exceed legal standards to apply a stricter barrier to youth.”

Measures put in place include Challenge 25; two-factor authentication for purchases on Juul’s website; billboards placed at least 200m from schools (double the official guidance); secret shoppers; and a ​“conservative approach” to flavour ranges and names.

Still, it can’t be denied that millions have taken-up vaping while still in their teens. Neither can the fact that Evali is caused from vape use. However, arguments over THC and street cartridges, have split the health community when it comes to assessing the actual risk posed by vaping store-bought nicotine pods.

According to Martin Dockrell, Public Health England’s tobacco control lead: “[the Evali outbreak] has nothing to do with nicotine e‑cigarettes. It’s cannabis vapourisers – e‑joints if you like. It doesn’t reflect on UK nicotine-containing e‑cigarettes at all.”

In the US, e‑cigarettes have zero regulation – a loophole in American law set to be closed by the FDA in May 2020. It’s a quirk that meant Juul’s claims that its products were safer than smoking were illegal. In the UK, we (still, just about) follow EU regulations. That means e‑liquids are restricted to a nicotine dose of no more than 20mg/​ml. In America, it’s a whopping 60mg/​ml.

It’s one of the reasons that Dockrell maintains that vaping is 95 per cent safer than smoking. He dismisses the reliability of some animal studies, like this one which, Eissenerg cites where mice were exposed to a regular vape aerosol. ​“The cells in their lungs were full of oils. They were coming from the lungs themselves – as though the lungs’ cells were gobbling up all these oils that didn’t belong there.” He adds that it’s the hallmark of lipoid pneumonia – a condition linked to the outbreak. But as Dockrell says: ​“In one, they took mice and exposed them for days on end on a concentration of nicotine at max US levels, one that’s meant for big humans. It tells us nothing of the cancer risk.”

And the 200 health problems in the UK from vaping? ​“Mostly, they are pretty minor: sore throats and coughs,” says Dockrell. He admits carcinogenic compounds exist in vapes – but not in everyday use. ​“Formaldehyde and acetaldehyde can be found, but only if you ramp up the device’s power to the degree that it creates those chemicals. But it’d be really unpleasant to inhale.” He adds, ​“If you wanted to hurt yourself with an e‑cigarette you’d be better off stabbing yourself in the eye with it.”

Still, despite there being a consensus that vaping is, by far, the lesser of two evils, a city and state-wide vaping clampdown is ongoing in the US: Massachusetts banned all products for four months; New York, Michigan, Rhode Island, and Los Angeles county outlawed flavoured e‑liquids; and San Francisco, HQ of Juul Labs, removed all e‑cigarettes from the shelves. In the past few days, Juul has suspended all sales of fruit-flavoured pods in the US.

Alongside bans and tightening regulations, there are further signs that vaping – and Juul – may have reached a turning point. ​“There’s one thing about youth fads and crazes – they never last,” muses Jackler. ​“It’s a terrible business plan. Kids are fickle.”

The latest teenage craze? Many are throwing their Juuls away. Jonathan is one of them. ​“The crisis in America has meant there’s a greater awareness of the dangers,” he explains, adding that Juuling at school has been on the wane this year. ​“I’ve seen a lot of people quit because of some of the tragic news stories on social media. I’ve pretty much quit too, but some of my friends are finding it difficult to give up.”

Vaping may be no way as lethal as cigarettes. But it’s not without risk. For instance, there’s the nicotine. Studies have shown that addiction to nicotine primes an adolescent brain for addiction to other substances – it’s basically a neural gateway drug. And now, as a result of vaping, there are millions of Gen Zers stuck with a hard-to-quit nicotine addiction. People like Jonathan. ​“It’s pretty clear that many vaping companies aren’t just trying to help smokers on their journey to quit,” he says.

“I think there was an element of deliberately targeting younger people. And the fact that the dangers of these products are being learned for the first time from victims – mostly young, underage customers – is pretty shocking.”