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Bans Won’t Prevent the Mysterious Illness Linked to Vaping

A Truthout reporter examines vaping through the lens of harm reduction.

Andy Ramkumar, who works at Gotham Vape in Queens, vapes at the store on September 17, 2019 in New York City. Vaping, which many Americans have taken up as an alternative to smoking, has come under increased federal scrutiny following a rash of deaths related to vaping cannabis.

After reading the latest headlines about a severe lung illness linked to vaping, I looked away from my computer to consider my options. To my left was a small e-cigarette vaporizer that delivers nicotine from flavored pods, much like a Juul. To my right is a cartridge full of a dark, honey-like substance I’ve been told is cannabis oil, which is attached to a battery that powers an internal vaporizer. A light puff off the cartridge delivers a moderate dose of THC that gets me a little high and relieves stress, depression and anxiety. I use the e-cigarette to avoid smoking tobacco cigarettes, something I’ve been trying to do for years. So far, it’s all been working. I haven’t smoked a cigarette in over a week, and I smoke less marijuana now that vaping is popular.

I like vaping and agree with experts that it’s probably safer than smoking, but what about this mysterious lung illness linked to vaping that’s all over the news? According to the latest numbers, more than 500 vapers across the country are reported to be suffering from the illness. At least nine have died. Could I be next? That’s difficult to know until researchers pinpoint the cause (or causes) of the illness. Unfortunately, the response by some in the government and media has further muddied the waters.

By now, public health investigators have found that most patients suffering from the lung illness vaped black market and counterfeit THC cartridges containing distilled cannabis oil cut with thickeners and other additives. Others who were using THC cartridges may have initially lied about what they were vaping, because cannabis remains illegal and stigmatized in many states. Observers suspect thickeners such as vitamin C acetate are contributing to severe lung problems. Contaminants have also been found in counterfeit THC cartridges, including pesticides leftover from growing marijuana and heavy metals like lead that leach from cheap cartridges. Cartridges are disposable, but some people re-use them and fill them with homemade concoctions, which could also pose risks.

However, President Trump and politicians across the country have responded to the outbreak of lung illness by moving to ban flavored nicotine vaporizers. (THC cartridges are already illegal under federal law.) Some states and cities are banning vape products altogether. Trump and others say sweetly flavored e-cigarettes attract teenagers to nicotine. Yet critics warn that discouraging vaping could push users of all ages back to cancer-causing cigarettes. Conflating e-cigarettes with THC cartridges has also confused nicotine and cannabis users looking for guidance on the potential harms of vaping and how they can be reduced.

According to a harm reduction guide for parents of teens who vape, there is a big difference between trying a drug like nicotine and using it often and heavily enough to cause health and social problems. While one survey found that 43 percent of 12th graders have tried vaping at some point in their lives, only 27 percent reported vaping in the past month. Harm reduction is a broad set of practices aimed at making drug user safer, and it’s based on the idea that some people will use drugs even if they are prohibited. Vaping nicotine is illegal for those under 18 and against the rules in most schools and many households, but many teens are vaping anyway. Harm reductionists argue parents should talk honestly with their kids about the effects of nicotine and should not shame or punish them if they do vape; this will only cause teens to hide their use, making it much harder to have honest conversations about their health in the first place.

Vaping nicotine instead of smoking tobacco is a harm reduction, but it still carries real health risks. Nicotine is highly addictive and can cause health problems no matter how it’s consumed, and preliminary research suggests that some e-cigarette flavors can damage blood cells and could increase the risk of heart disease. The pod in my e-cigarette is flavored like tropical fruit, something I like but could live without if candy-like flavors are banned. I’ve used Juul pods, which no longer come in candy-like flavors, and they were just fine, besides being a bit expensive. However, if nicotine vapes disappeared from the store shelves altogether, I could see myself asking for a pack of cigarettes. Same goes for a number of my friends. Medical experts and harm reductionists are worried about this trend on a broader scale, as politicians discuss vaping bans.

Research shows that vaping nicotine is 95 percent less harmful than smoking cigarettes, which contain tar and cancer-causing chemicals. Hundreds of thousands of people die from smoking-related illness in the United States every year. Vaping hasn’t been around as long, but e-cigs contain far fewer dangerous chemicals than tobacco. While the Centers for Disease Control cautions that a small number of people suffering from the lung illness in the headlines only reported using e-cigarettes, not THC cartridges, some also initially lied about using THC. Plus, research shows that vaping is more effective than nicotine gum and other replacements at helping people stop smoking, and addiction experts consider vaping a crucial harm reduction measure for millions of adults.

If I stop vaping, I risk relapsing back to tobacco. I decided to keep using my e-cigarette. I know vaping nicotine is not harmless, and vaping by itself is not a nicotine cessation strategy. Some people end up using more nicotine after switching from cigarettes to nicotine vapes. So, I make a strategy to reduce my consumption and eventually quit. I’m going to track how many cartridges I use over a few days and make an effort to use less. I’m going to purchase nicotine gum or pouches, which will reduce my cravings when I’m socializing and vape the most. This is the harm reduction strategy that works for me as an individual; others may choose a different strategy.

My THC cartridge is a very different story. THC cartridges are popular because they are convenient and discreet, as the media has widely noted. However, many reports fail to note that cartridges are also popular because the vaping system itself can be used for harm reduction. Dosage is very important to cannabis users; too little THC won’t produce the desired effect, while too much causes unpleasant side effects such as anxiety and paranoia. Research shows that low and moderate doses of medical cannabis produce the most benefits for patients, while high doses can make symptoms worse. So, cannabis users tend to self-titrate, or find the correct dose on their own. Many batteries attached to cartridges make this easier with different temperature settings for vaporizing the cannabis oil. Users can adjust the temperature based on their individual tolerance to THC, take a light “sip” from the vape pen, and see how they feel before taking another. For some users, this may be a more exact way to titrate than, say, eating a homemade weed brownie or smoking a joint. I like my THC cartridge for this reason — but now I’m worried it could contain additives suspected of causing lung illness.

A number of cannabis products, including raw flower and various concentrates, can be vaporized for consumption, but it’s disposable cartridges and oil pens that are implicated in the outbreak of lung disease. I live in a state where THC remains prohibited, and as cartridges became more widely available on the local illicit market, users assumed they were legally manufactured in regulated states and then shipped to areas under prohibition. We now know that law enforcement crackdowns on the black market cannabis supply, along with the availability of cheap knock-off cartridges and packaging, have created a market for counterfeit cartridges that look like brand names from legal states but are often cut with additives and sold for much lower prices. In California, for example, regulators require legal cannabis products to be tested for pesticides and heavy metals, but there’s no way for a casual user to know what’s in a counterfeit cartridge.

My THC cartridge was a gift from a friend, who obtained it for free from an illicit distributor. The THC oil lost flavor and turned from gold to brown over time, making the cartridge difficult to sell. That concerns me. It’s not labeled, and I have no way of knowing whether it was filled by a regulated company in a legal state that submits products for testing, or by unregulated distributors in the black market. Test kits for other illicit drugs, such as MDMA and heroin, are distributed by harm reductionists so users can test the substances for dangerous additives, but no such equipment currently exists to test THC oil.

I decide I’m not going to use the cartridge. Instead, I’ll vaporize raw cannabis flower with a different device called a dry herb vape, which is considered safer than smoking and recommended by cannabis experts following the outbreak of lung disease.

I know someone who sells illicit THC cartridges, so I ask them if news linking the mysterious vaping illness to black market cartridges is putting a damper on sales. Not at all, she tells me. If anything, sales are up. Is she worried about selling people products that could make them sick? She has used cartridges from her source for over year without any problems – and they are not “sketchy counterfeits” of name brands. The word on the street – and in many of the headlines – is that cheap, counterfeit cartridges cut with lots of additives are likely causing the lung disease. Her cartridges are “legit,” she says, because they were manufactured by a reputable cannabis company and then sold in the black market. They cost about as much as cartridges sold at dispensaries in legal states – between $40 and $60 dollars – and she warned that counterfeits are being sold for half as much. Still, there’s no way to confirm her product’s safety without testing the contents or following a supply chain operating in the shadow of the law.

While public health officials still don’t know what is causing the lung disease linked to vaping, cannabis prohibition is now looming large over the story. If cannabis were legal and regulated at the federal level, the government could write new rules for testing and selling THC cartridges once researchers determine what is causing the lung disease. In states where cannabis is legal, regulators are already racing to do just that. While counterfeits are showing up in legal states, consumers can still choose to buy cartridges from reputable, licensed dispensaries and manufacturers that are required to test and label their products.

But cannabis remains a Schedule 1 drug under federal law, classified alongside LSD and heroin, leaving millions of black market consumers in the dark. Under cannabis prohibition, federal regulators are powerless to enforce safety standards. Federal law enforcement will continue targeting the illicit THC oil supply, but crackdowns on that supply chain probably pushed distributors to start cutting THC oil with additives in the first place.

This explains why Trump is targeting flavored e-cigarettes, even as counterfeit THC cartridges increasingly look like the culprit. The Food and Drug Administration can regulate tobacco products, providing a place for federal policymakers to intervene, even if it doesn’t strike at the heart of the issue. This follows the broken logic of prohibition: If there’s a problem, ban something. However, prohibition always has unintended consequences. There are plenty of recipes for making flavored nicotine vape juice online, and a ban on flavors would undoubtedly lead to broader use of unregulated, bootleg e-juice with unknown risks.

Prohibition has never eliminated the supply of any drug. Instead, prohibition creates unregulated black markets where distributors have incentives to cut their drug supply with additives in order to make more money. Prohibition makes drugs (and the drug trade) more dangerous, as we are likely seeing with counterfeit THC cartridges. Consumers buying drugs from the black market are forced to make health decisions with less information, because drugs are not tested for quality and clearly labeled. The broken logic of prohibition is still shaping our nation’s drug policy, and so far, the latest news about vaping – and the moral panic that followed – is resulting in more prohibition instead of reform.