On the latest episode of Policy Outsider, guests Heather Trela, director of operations and fellow at the Rockefeller Institute, and Trevor Craft, graduate research assistant, share insights from their research on the national vaping crisis. Trela and Craft discuss how the growth of vaping tobacco products in teens and the emergence of vaping-related lung injury created what we now call the vaping crisis. The episode explores what actions local, state, and federal governments are taking to address the crisis and how their responses are complicated by unusual regulations surrounding vaping and marijuana.


Heather Trela, Director of Operations and Fellow, Rockefeller Institute of Government

Trevor Craft, Graduate Research Assistant, Rockefeller Institute of Government


  • Transcript

    Transcript was generated using AI software and may contain errors. 

    Alexander Morse 00:03

    In the summer of 2019, a mysterious respiratory illness began appearing in the Midwest. As it spread throughout the country, public health officials ruled out possible causes such as bacterial infections and pneumonia before ultimately identifying vaping as the most likely culprit. The onus appeared in the midst of skyrocketing rates of youth e-cigarette use and sparked a backlash against manufacturers of these devices. Yet, the early evidence suggests that the illness is tied to the use of unregulated vaping cartridges with tetrahydrocannabinol or THC, the main psychoactive component found in marijuana. On today’s episode of Policy Outsider, we examine two distinct vaping-related public health crises that are occurring simultaneously and explore the connections between the two. We also look at how states are developing and implementing policies to manage these crises. Lastly, we’ll gain insight into the challenges of researching such rapidly evolving issues and how changing landscapes affects policymakers seeking to address these issues.

    Alexander Morse 01:21

    With me today, I have Heather Trela, director of operations and fellow at the Rockefeller Institute, and Trevor Craft, a graduate research assistant at the Institute, who have both been researching this issue over the past few months. Thank you both for joining today.

    Heather Trela 01:35

    Thanks for having us, Alex.

    Trevor Craft 01:36

    Thanks for having me.

    Alexander Morse 01:37

    Heather, I want to open up this conversation with you. We hear the phrase in the media a lot, we’re in the midst of a vaping crisis. What does that mean?

    Heather Trela 01:45

    Let me start by defining what vaping is because it’s a catchall term. Vaping is the inhalation of a vapor created by an e-cigarette or other vaping device. These are battery powered and they usually have cartridges filled with a liquid, sometimes nicotine, sometimes flavorings, and sometimes other chemicals like THC. The liquid is heated into a vapor, which the person inhales hence vaping. There’s two fronts of this current crisis that’s been in the news a lot. The one that’s more high profile right now is the sicknesses that are associated with vaping. What they are, who is getting it, what’s causing it, they’re still trying to figure all these things out. The second phase is the growth of vaping amongst teenagers that has skyrocketed in the last few years.

    Alexander Morse 02:27

    The emergence of these cartridges is happening at the same time that there’s this explosion in vaping tobacco amongst teens. Can you share some of the background on this growth in teen vaping?

    Heather Trela 02:36

    It’s important to note that when we say vaping, we’re going to try to distinguish between vaping with tobacco and vaping with THC, because those are going to have important ramifications for policy down the road. Teen vaping in and of itself and the concern about it is not necessarily a new issue. Back in December 2018, the surgeon general issued an advisory on e-cigarettes among youth, declaring the growing problem to be an epidemic. However, this has become even more highlighted by the recent illness and injury that we’re seeing with people who have engaged in vaping. Teen vaping has been on the rise, the New England Journal of Medicine has done surveys to see how often students in twelfth grade, tenth grade, and eighth grade have engaged in vaping in the last 30 days. Just from 2017 to 2019, we’ve seen those numbers double. For those in twelfth grade, there’s been a 14.4 percent increase in teens that reported vaping. For eighth grade, it’s gone up 5.5 percent between 2017 and 2019. Those are the students that have reported smoking in the last 30 days. Again, this is self-reporting, so you have to assume these numbers are on the conservative side. It might actually be much higher. For teens who have reported trying vaping in the past year, we see similar trends from 2017 to 2019, twelfth graders had a 16.3 percent increase, and eighth graders had an 8.6 percent increase. That’s just over two years and there doesn’t seem to be any signs of that slowing down.

    Alexander Morse 04:00

    And Trevor, you’ve been doing a lot of research on the respiratory illnesses that emerged earlier this year. As I mentioned at the outset, the evidence now suggests that the illness is tied to unregulated THC cartridges popping up in the black market. What is our latest understanding of the illness?

    Trevor Craft 04:15

    The CDC has given it a name, e-cigarette and vaping product use-associated lung injury. They’ve moved their terminology away from illness in the sense that it’s not caused by bacteria or viruses, but it’s something that is being caused by inhalation of a foreign substance that’s causing some acute injury as opposed to being into long-term illness. The symptoms present themselves as coughing, increasing shortness of breath, and inability to be able to fully inhale essentially. You get chest pains, you get coughing, gastrointestinal distress. So far, the CDC has identified as of November 21, there have been 2,290 cases, 47 deaths in all states except Alaska, the District of Columbia, Puerto Rico, and the Virgin Islands. THC use was a correlation in 83 percent of the cases, while nicotine was in 62 percent. There was a 35 percent reporting of exclusive THC-cartridge use and 12 percent reports of exclusive nicotine use. Seventy-seven percent of the cases are people under 35. So this is a primarily young person’s injury so to speak. The median age is 24, while 53 percent of all the cases are 24 and under. The biggest incidents of where you’re finding these injuries are in states where cannabis is still illegal for adult-use. The highest incidences are in Illinois, Texas. New York has a lot of them, they’re not quite front-runners. Interestingly enough, California has a high incidence rate similar with Illinois but they have issues with the black market cannabis in their state.

    Alexander Morse 05:50

    That’s interesting that you bring that up because many of the states you had mentioned, they don’t have the legal marijuana market, so that means it’s ripe for a black market. We know California had their issues with their implementation of their marijuana programs, so the black market still exists.

    Trevor Craft 06:07

    Yes, there have been references to the black market being approximately three times the size of the legal market in California. It’s hard to get factual statements about how big a nonregulated market is because it’s very hard to measure. But the anecdotal reports and some of the preliminary stuff that the California departments have been putting out make it seem as though the black market’s substantially bigger than it is to the legal market. As far as the injuries is concerned, the CDC has identified Vitamin E acetate as being one of the compounds that they’re most interested in, but trying to find out what this injury actually is. Vitamin E is used in topicals. It’s used in supplements. It’s healthy for your skin. It’s healthy for ingestion, but it was never approved for inhalation. There’s a lot of reports that this was ending up in these unregulated vaporizer cartridges over the summer. Many people believe that this is the causal factor. It’s hard to say though because there have been a lot of other compounds of interest that have been found in these cartridges, like high levels of pesticides and fungicides that lead to hydrogen cyanide breakdown. There’s heavy metals and lead. There’s all sorts of different things inside of these cartridges that are potentially injurious. So it’s not just vitamin D, but looks like it.

    Alexander Morse 07:14

    For all of these added products you just mentioned, do we have any explanation as to why it’s being found in these illicit cartridges?

    Trevor Craft 07:22

    From what I’ve been reading, it seems as though Vitamin E made its way into these cartridges after illicit distributors started cutting their oils with other oils. They would take something called propylene glycol, it’s commonly found in e-cigarette vapor liquids. They would use MCT oil, medium-chain triglyceride, it’s derived from coconut oil. These injuries weren’t popping up then but what was happening was that the oil would become runny. So consumers would notice and they would think it was low-quality oil. There were a couple of legal companies that actually popped up that started selling thickening agents, one was called HoneyCut. There’s a couple different ones.

    Heather Trela 08:03

    In a lot of ways, it just comes down to supply and demand. On the black market, they’re trying to stretch the THC, which is not necessarily easy to get, especially in states where it’s not legal. One way to get more bang for your buck and make that supply lasts longer is to cut it with other agents. The dealers are also looking at a way to make more money with using less of the drug.

    Trevor Craft 08:23

    Once those got introduced into the market, these injuries started popping up. This is a very new development in the black market using these cutting agents. Interestingly, on this front, the New York district attorney has subpoenaed the three companies responsible for distributing these thickening agents. All three of them have pulled their products off the market and one of them has disappeared entirely.

    Alexander Morse 08:45

    We have these two public health crises occurring at the same time. There’s this explosion in vaping tobacco products amongst teens. Then in the summer, people started dying from this, as Trevor pointed out, it’s not an illness but an injury. We now think these injuries are related to the illicit THC cartridges. These injuries almost serve as kind of a spark for the response that we’re seeing. Trevor, I like how you mentioned that New York is taking action against a couple of companies. It brings us to the policy response. What have the states and federal government done and what are they considering doing to address the vaping of tobacco and marijuana products?

    Heather Trela 09:22

    It’s a good federalism story. Now, the FDA did not get authority over e-cigarettes until 2016. These products are still out there without FDA approval. They actually moved the goalposts for that for approval to 2022. The states have stepped into that vacuum to try to regulate what they can regulate. Again, because there were so much uncertainty with what was causing these illnesses, it was easier to address the youth problem rather than the potential of Vitamin E acetate problem. A bunch of states have either tried to ban flavored products, both for tobacco and THC products, in states where that’s legal, to try to minimize the appeal to teens. The idea being that a teenager is more likely to vape cotton candy, mango, tooty fruity than an adult. Some states, the bans have been successful. A lot of the states have been blocked by the courts because they’ve been done by executive action. Most of these bans were temporary to give states time to figure out what to do, so in some of the states where these bans have been blocked, like New York State, is a legal challenge against the ban against flavored vapes. There are states that are considering legislation. Right now, Massachusetts looks like they could be the first state to legislatively ban all e-flavored cigarettes and tobacco products and THC products. That’s moving through the legislature right now. In some states like Colorado, they specifically targeted Vitamin E acetate and targeted that as being prohibited from use in any products in the state. Other states have also tried to raise the age, New York being the most recent that has increased the age for vaping and cigarettes from 18 to 21. That just went into effect this month. Not only are individual states and cities trying to address the vaping problem, but we’re starting to see the formation of regional coalitions to address vaping. Recently, as part of a discussion about legalizing marijuana and also the threat of vaping, we saw representatives from the states of New York, Massachusetts, Connecticut, and New Jersey, all come together to see if they could find a general common consensus on how to move forward and how to make sure all the regulations were in line with each other to protect their residents and to make the most effective policies possible. Now the federal government has indicated that they could possibly step in. Back in September, the Trump administration announced that they were looking into the potential of banning all flavored e-cigarettes in the United States, including mint and menthol flavors. States were, to some degree, waiting to see what the federal government was going to do. However, just earlier this month in November, President Trump announced that they were backing off of that. They were going to have a series of meetings involving members of the vaping industry, as well as doctors, to discuss the problems. There was not going to be quite the immediate action that some states may have thought. Some states are also going after the companies, primarily Jewel, that create e-cigarettes for predatory advertising, targeting youth, and for unfair practices and advertising. New York has joining this case. California has joined. North Carolina was actually the first state to sue earlier this year. I think you’re going to start seeing a wave of lawsuits targeting the manufacturers as well. Because vitamin E acetate has been identified as a primary cause of the vaping injury, that’s by the CDC and it’s primarily being found with cartridges use THC, this has become a problem for the marijuana industry and highlights one of the issues operating under the shadow of a federal ban on marijuana. Because marijuana is not federally regulated, states have to come up with their own regulations for the legal marijuana industry in their states, which means there’s no consistency and what states are testing for in their products to make sure that they’re safe. They’re doing the best that they can but there is no general consensus. Part of the problem with that is also because of the federal ban, there has not been a ton of research done on the impact of marijuana, THC, long-term. Knowing what to test for, you don’t always have a good medical background to rely on in diagnosing a problem for the CDC. Part of the problem was this was all self-reported injury. A lot of people were saying that they did not use THC, potentially, because it’s illegal in their states or it’s a federal violation. Self-reporting could have skewed some of these numbers. Where many of the people who said they did not use THC cartridges had THC in their system when they actually had their medical examination done. That causes each state to become its own little mini-FDA without a lot of consensus. Without that kind of regulation. I’m sure they’re going to start testing for Vitamin E acetate now, but this shows a limitation of the industry because of a lack of federal oversight. To date, I think nine states have tried to put restrictions on vaping.

    Alexander Morse 14:02

    Let’s clarify that. Are we talking about vaping tobacco products, marijuana products, all vaping?

    Heather Trela 14:08

    It’s going to depend on the state and what the legal status is of marijuana. In states where they have legal adult-use marijuana or recreational marijuana, the bans on flavors would apply to them as well. There are often exceptions for medical marijuana because it’s typically not flavored products.

    Alexander Morse 14:23

    We have a summary of which states have banned what?

    Heather Trela 14:25

    A lot of these bands have been challenged in the courts, so they’re no longer active. But Massachusetts, the governor has declared a public health emergency and ordered a four month ban on all vaping product sales. Michigan’s ban on flavored e-cigarettes was blocked by the court. As was New York’s, as I mentioned earlier. Rhode Island was able to get theirs through a court challenge and they’ve banned flavored vaping products. Oregon, also blocked by the court. Washington State is a little more comprehensive in their regulation of vaping. Not only do they ban the sale of flavored vaping products, but they also ask that all vaping shops have signs indicating the potential for injury if you do engage in vaping, and they require the reporting of any lung injury to their state health department. Colorado took a slightly different angle, as I mentioned, they focused on Vitamin E acetates. Utah, their ban was also blocked by the courts, as was Montana’s. Now, California as a state, did not take on any sort of ban. But San Francisco has done so and Los Angeles is considering it. I believe New York City as of today, November 22, the New York City Council has passed a ban on flavored vaping products that will have to be signed by the mayor to go on. But that would be the largest city to have implemented a ban. As you can see, this is not just states stepping in local governments are also trying to regulate this as best they can. Albany County recently tried to ban flavored vaping products in the county as well but it did not pass. It’s trickling down to the lower levels of government as well.

    Alexander Morse 14:27

    As we’ve heard so far, we’re seeing that there’s inconsistencies between states and their policies and their regulations and their bans even at the different levels of government. We also have heard about the uncertainties and what the cause of the problem the injuries are or why more teens are vaping. Trevor, I want to ask you, maybe if you can share a little bit about the challenges you faced trying to stay ahead of all this new information. This changing information, and how we can research vaping in real time.

    Trevor Craft 16:29

    Well, you pointed to the most pressing challenge for all this is that it’s current information that’s constantly changing. When the injury first started popping up, no one had any idea what was happening. Then there were some early adopters of the idea that it was Vitamin E started basically shouting from the rooftops. But then as the case evolved, things happen, like the New England Journal of Medicine posted a study about how this looks more like a chemical burn than Vitamin E contamination. Then there was a lot of backtracking, where New York tries to ban flavors and then it doesn’t seem to be targeted at the correct variable. There’s just so many different things that happened in real time that it makes it difficult not only for us as researchers to figure out what is actually happening here, what are the targeted interventions that need to actually happen in order to address the problem. If it’s hard for us, it’s going to be hard for policymakers as well. There’s the expectation of action when we’re sitting in a situation where we don’t even really know what’s going on.

    Alexander Morse 17:34

    The vaping crisis continues to evolve and so has the response. Since we recorded, researchers in Canada identified a new kind of vaping-related injury with symptoms resembling popcorn lung, an irreversible lung injury caused by chemical exposure from products typically found in microwavable popcorn. Earlier in the episode, we heard Heather talk about Massachusetts and some of their legislation to ban all flavored tobacco products. While in the final week of November, Governor Charlie Baker signed that legislation into law. I’d like to thank my guests, Heather Trela and Trevor Craft, for coming on today to discuss their research into the vaping crisis and breaking down some of the science behind the injury and how the different levels of government are responding. You can check out their research and more from our great team of researchers by visiting our website at www.rockinst.org. Lastly, this is our final episode for the year 2019. I hope you enjoy tuning in to learn about how policies entwined with everyday life and the importance of quality research to help inform our decisions. We love the challenge of working on our research and bringing it to you in audio form every month and we’re excited about 2020. Until then, I hope everyone has a fun and safe holiday season and a happy new year. I’m Alex Morse, until 2020.

    Alexander Morse 19:07

    Policy Outsiders is presented by the Rockefeller Institute of Government, the public policy research arm of the State University of New York. The Institute conducts cutting edge nonpartisan public policy research and analysis to inform lasting solutions to the challenges facing New York State in the nation. Learn more at rockinst.org or by following at RockefellerInst on social media. Have a question, comment, or idea? Email us at [email protected].

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Policy Outsider” from the Rockefeller Institute of Government takes you outside the halls of power to understand how decisions of law and policy shape our everyday lives.

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