In 2018, Juuls appeared to be as essential as dad sneakers and fanny packs to a certain young-Hollywood set. Bella Hadid, Sophie Turner, Dua Lipa, Miley Cyrus, Kate Moss — plenty of your faves were seen carrying one. But mark Fall 2019 as the death of the toking trend: E-cigarettes and weed vape pens became linked to a mysterious-yet-deadly lung illness epidemic, effectively killing their cool.
In early 2020, we have a lot more clarity: The majority of the 2,500 hospitalizations and 54 deaths from EVALI (that’s the acronym for the e-cigarette or vaping product use-associated lung injury) were likely due to vitamin E acetate, which had unknowingly been added to the devices.
And, following the initial reports, the state of vaping culture began to look up: The EVALI outbreak peaked in September and, once the CDC was able to identify the main culprit, the FDA and the Drug Enforcement Administration started cracking down harder on illicit cartridges as part of "Operation Vapor Lock." Michigan, Oregon, and Massachusetts (among other states) flat-out banned sales of all flavored e-cigarettes temporarily.
At the end of 2019, the FDA upped the federal minimum age to buy tobacco from 18 to 21. And today, new legislation goes into effect for a nationwide partial ban on many flavored e-cigarette products like Juul.
But the sunshine isn’t really the whole story: A newly released report from the Centers for Disease Control and Prevention (CDC) says that while the worst of the outbreak is likely over, states are continuing to see new cases of EVALI on a weekly basis. Celebs are still seen toting the electronic accessory. And the new legislation against flavoring features a few technicalities that allows disposable e-cig brands to still use the harmful pods, and even reusable vape giants like Juul to still sell a few of their flavors.
The new laws and new reports leave plenty of questions left swirling — what vapes are we supposed to stay away from, which ones are safe, and how do you protect yourself from ending up in the hospital? Here, we break down what we know — and what we still don’t know — about the safety of e-cigarettes and vape pens.
Are All Vape Pens the Same?
There is a foundational similarity in the devices themselves: Vape pens are battery-powered — usually small, sleek, and discreet — and are comprised of four main parts: a battery; sensor software to help power it; an oil cartridge that contains the substance you're trying to inhale (usually THC or nicotine), along with carrier oils and potentially flavorings and other compounds; and a small heater called an atomizer that converts the liquid oil into tiny droplets for you to inhale.
Beyond the basics of construction, all vapes are definitely not the same. For starters, we have two main categories: weed/cannabis vape pens and e-cigarettes. Cannabis oil vape pens sometimes contain CBD, but usually contain THC, the psychoactive substance that produces the “high” associated with smoking marijuana. The CDC reports that about 82 percent of people hospitalized with the mysterious pulmonary illness had used a THC vape in the past 30 days.
This caused most everyone to point the finger at weed vapes — and some of that flak is warranted. "The world of cannabis vapes is largely an unregulated space, which means you can have unscrupulous people cutting the products with who knows what," says Ray Niaura, Ph.D., professor of social and behavioral sciences at NYU and former president of the Society for Research on Nicotine and Tobacco.
Among those questionable compounds is vitamin E acetate, which was found in many of the pens that belong to hospitalized folks then tested by the CDC.
But 14 percent of the people hospitalized with vaping-related illnesses exclusively used e-cigarettes, never touching a weed pen. Plus, a large percentage of the patients (nearly half) vaped both THC and nicotine — and that points to an issue that goes beyond THC or nicotine itself, and instead is tied to the vaping devices themselves (e.g., how hot they get) and extraction process (namely, the carrier oils in the cartridge), says Stanton Glantz, Ph.D., director of the Center for Tobacco Control Research and Education at the University of California San Francisco.
We now know vitamin e acetate was a huge culprit in harming health. But “more than any risk of nicotine or cannabis, most of the compounds used as carriers in these products are not good for your health,” Glantz says. (More on that later.)
Lastly, we have the difference among e-cigarettes themselves, which is mainly around how clean the formula is for the vape oil, and how hot the device is able to get. "Most of the carrier compounds in an e-cigarette become formaldehyde when they are heated too high. And the hotter it heats, the more breakdown of all the compounds you're going to get," says Glantz. One pro for Juul compared to other brands is their pens have more advanced technology that prevents it from overheating and combusting, Niaura points out.
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What Is a Juul Anyway?
Juul is hands-down the most popular brand of e-cigarettes. In fact, it’s likely the only brand most people could name. But every e-cigarette isn’t a Juul and, even though it, like all e-cigs, isn’t regulated by the FDA, the more advanced Juul technology and public exposure makes it one of the safest forms of e-cigarettes, says Niaura. (More on why it’s considered ‘safer’ below.)
Are E-Cigarettes Safer Than Regular Cigarettes?
Yes. E-cigarettes were created for and are marketed as products for current smokers trying to quit. And in that context, they’re definitely healthier: Ditching traditional smokes for the electronic variety reduces your exposure to some toxicants and carcinogens, says a 2018 study in JAMA. They help you quit better than nicotine patches, and a lot of ex-cigarette smokers say they feel less dependent on e-cigarettes than they remember being on the traditional stuff, according to a 2015 paper from Penn State. Meanwhile, European researchers found that former smokers who switched over to e-cigs exclusively experienced less nicotine withdrawal and less exposure to toxic cigarette smoke after two years.
So, Are E-Cigarettes Safe?
No. Unless you’re using them to try to quit smoking (and even still then), e-cigarettes can only harm your health. For one, they often still contain nicotine, which is highly addictive; and they have been linked to serious long-term side-effects.
We know traditional cigarettes are terrible for your heart and lungs, but a huge study review in the Annual Review of Public Health found that e-cigarettes increase the risk of lung and cardiovascular disease at similar rates. In fact, they double your risk for stroke compared to just sticking with traditional cigarettes — and nearly triple your risk for the major killer compared to steering clear of the stuff entirely, says a new study in the American Journal of Preventive Medicine. What’s more, e-cigarettes significantly up your risk for a stroke at a younger age, since people are toking younger and younger, the study authors point out.
Other research has found the electronic variety also increases your chances of chronic bronchitis. Additionally, they up your chances of having a heart attack and, since most who puff on e-cigs also still use traditional sticks, dual-users' risk of a heart attack is actually five times higher than people who don't smoke at all.
The flavorings are another huge issue. For starters, it’s the feature authorities blame on enticing so many teenagers into picking up the e-sticks. But the compounds used to make e-cigarettes taste better are also really, really bad for teens and adults alike.
Harvard researchers analyzed 24 different flavored e-cigarette brands on the market in 2017 and found all of them had at least one aldehyde or chemical on FEMA’s “High Priority Chemicals” or the FDA’s Harmful and Potentially Harmful Constituents lists. Meanwhile, more than 60 percent of the samples contained diacetyl, a chemical known to tear up your respiratory system and cause “popcorn lung” (that's a condition that damages your smallest airways and makes you cough and feel short of breath all the time).
What About the New Legislation Banning Flavorings?
One upside of the EVALI outbreak was lawmakers and manufacturers began to publicly recognize the damage flavorings in both e-cigarettes and cannabis vape pens do to users’ health. On February 6, 2020, a nationwide ban on many flavored e-cigarette products went into effect.
However, loopholes in the policy mean the ban really only applies to pre-filled pods that are compatible with reusable vaporizers like Juul — that is, disposable e-cigarettes and e-liquids not in pod form (like those largely found in vape shops and convenience stores) can still legally contain harmful flavorings, the New York Times points out. And even reusable brands like Juul are still allowed to sell a few flavors, like menthol and tobacco.
The flavored pods that are banned will have to now go through FDA approval to return to the market. That’s generally a good thing — but considering major killers like cigarettes are approved by the FDA, it doesn’t really speak to a safer future.
So while e-cigarettes are a little safer thanks to the new law, it’s only if you’re really seeking out the safest option.
What About ‘Black-Market’ Vaping Products?
At the height of the EVALI outbreak, you may have heard that the only danger was with 'black-market' vape cartridges. But in reality, nothing is currently regulated by the FDA (while they’ve had the authority to oversee e-cigarettes since 2016, they have yet to enforce any guidelines or approve products like Juul as safe for use; and cannabis is still illegal at the national level). That means all e-cigarettes and all weed vape pens (other than those sold at a dispensary, which are at least regulated by the state) are actually black market purchases. In other words: The FDA is not checking any vape products for safety, so there is no inherent trust in brand names you recognize.
Why the Real Issue Is Vaporizing Itself
The main issue with vape pens — cannabis or tobacco — is the actual process of aerosolizing. "Aerosolizing creates tiny microparticles about one-hundredth the size of a human hair that are small enough to enter the alveoli, the tiny air sacs in your lungs,” Glantz explains. Those particles that are entering your lungs are the substances from the vape oil itself.
Which leads us to the second biggest problem — and the main reason we’re seeing all these pulmonary issues now: the questionable compounds used as carriers in both nicotine and THC vape pens, like vitamin E acetate, propylene glycol, and vegetable glycerin.
Niaura points out these last two compounds — propylene glycol and vegetable glycerin — are in the foods we eat every day, so we know they’re safe to consume. But that says nothing of how safe it is to heat up these substances to extremely high temps and breath them in as vapor.
What we do know: While the CDC has officially labeled the mysterious pulmonary illness as an ambiguous “e-cigarette or vaping product use–associated lung injury (EVALI),” some of the cases were diagnosed early on as (and still follow the properties of) lipoid pneumonia, a condition where the lungs become inflamed because fat particles enter the lungs. In this case, that fat is oil from a vape pen, Glantz says. Tissue samples of one of the men who died in St. Louis showed cells stained with oil, the New York Times reports. And cases of lipoid pneumonia from e-cigarettes have been turning up in England as well, one of which last year involved a young woman who was hospitalized for a serious cough and respiratory failure. A biopsy revealed she had vegetable glycerine from e-cigarettes in her lungs.
The Bottom Line On Vape Pens
In short: Until the FDA starts regulating vape pens across the board, we have no guarantee the compounds used in the oils are safe when heated and aerosolized. Banning the majority of flavorings is a good start and raising the buying age to 21 is immensely helpful, but they’re really just bandaids for deeper wounds.
We know that unless you’re trying to quit traditional cigarettes, the electronic variety will only harm your health (jury’s still out on whether that applies to weed vape pens or not). And even if you’re using them to quit, you are substituting one harmful habit for another, and quitting entirely is the best bet.
The silver lining, as Niaura points out, is that this epidemic is motivating major e-cigarette companies, including Juul, to obtain FDA approval for use as a smoking cessation aid, which means the products will have to be proven safe for that use to be approved.
The good news: The deadline set by the FDA four years ago to regulate e-cigarettes is finally here. By May 12, 2020, manufacturers for all vaping products have to submit their applications to the FDA for sales authorization or pull their products off the shelf. Under law, their stock can still remain in stores for another year while the FDA reviews their application. But questionable companies thriving in the gray area of loose regulations now who know they won't pass the safety standards likely won't bother applying, which means their seriously unsafe products will be off the market by mid-May, too.
The takeaway for now? While e-cigarettes are healthier than the traditional kind, and one of the best options to help you quit smoking (and Juul may be one of the safest brands available), they’re still not guaranteed to be safe. No matter what your favorite celebs are up to.
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