I’m an American doctor. Here’s the truth about Juul, vaping and legalizing marijuana

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As a physician, I believe the medical community has a solemn responsibility to adhere to facts and evidence over hype and sensationalism. This is especially true when it comes to public health, for it is an integral part of our Hippocratic oath to “first, do no harm.” Yet it is with great dismay that I’ve seen the medical community in both the mainstream press and on social media resort to fear-mongering and mob-like scapegoating when it comes to the nuanced complexities of the vaping epidemic in the United States. A UCSF Professor of Medicine and Director of the Center for Tobacco Control even tweeted that those who vape “would be better off just smoking.” 

When doctors ignore actual evidence, we exploit our credibility as healers to promote our own agendas — which can ultimately cause great harm to patients. 

Every year more than 480,000 Americans die from cigarette smoking and more than 41,000 die from secondhand smoke. That means that in just one hour, more than twice as many Americans die from tobacco smoke than everyone who died from vaping-associated lung injuries thus far. While we must take the vaping epidemic seriously — especially when it involves children and young teenagers — comparing the two in terms of harm is like equating the thousands of fatalities from car accidents to the extremely rare but attention-grabbing airplane crashes that occasionally grip the news. In terms of harm reduction, air travel is orders of magnitude safer than driving, so convincing people to drive rather than fly can actually cause more deaths and injuries, despite how strongly a fiery crash stirs our fears.  


The same holds true for e-cigarettes. Stories of previously healthy young patients suddenly falling ill after vaping, needing to be intubated and hooked to breathing machines, is extremely jarring and heartbreaking. But when it comes to public health, evidence matters more than emotions. While the long-term effects of vaping are unknown, e-cigarettes may be 95 per cent less harmful than smoking according to Public Health England. But even beyond that, it appears the medical community and politicians may be pointing the finger at the wrong place. According to the CDC, it is likely that black market cannabis vaping materials, rather than legitimately sold and tested e-cigarettes, are the primary cause of the acute lung injuries that have tragically claimed the lives of 26 people so far. Yet it is the legitimately sold e-cigarettes that are now subject to local government bans across the country from New York to Massachusetts to California, potentially driving vapers to use far more deadly traditional cigarettes.

Because marijuana is illegal under federal law, an entire do-it-yourself black market vaping industry has risen to meet illicit demand in the same way moonshine grew in popularity during the Prohibition era of the 1920s. And just like moonshine, which came with contaminants like lead and methanol from using automotive radiators as stills that led to blindness and death, these black market THC vapes are proving to be equally harmful and deadly.

Adapting the same e-cigarette technology used for nicotine vaping, THC vapes use a lithium-ion battery to send electrical current through a wire that is coiled several times to create resistance and heat. An absorbent wick, usually cotton, brings the e-liquid to the heated wire, which is then aerosolized and inhaled by the user. At every step for every component it takes to make these black market vapes, there is the potential for disaster. 

For example, there are smartphone apps, like Pocket Vapor Calculator, that instruct users on how many turns of the wire to make to achieve a desired resistance for the desired amount of heat. But if there’s a miscalculation — say, making too many turns of the wire or using wire that is too thin — then the vape pen can vaporize a slew of toxic metal and nickel nanoparticles that can damage the lungs and perhaps even cause acute eosinophilic pneumonia. That’s a rare disorder where immune cells called eosinophils to migrate to the lungs, resulting in incredible damage. Acute eosinophilic pneumonia has been observed in some of the patients with vaping injuries. 

Then there’s the matter of the black market e-liquid itself. A few early but conflicting reports suggest that the vaping-associated lung injuries resemble lipoid pneumonia, a rare disease that can occur when a patient inhales an oily substance that gets into the tiny air sacs of the lungs. Oil in the lungs where it doesn’t belong causes massive inflammation and damage. We’ve seen this in children with cerebral palsy and elderly patients who have accidentally inhaled or aspirated mineral oil-based laxatives. But it can theoretically occur with black market vaping pens too, especially if they have been adulterated to contain high amounts of oil in the e-liquid that is aerosolized and inhaled. 

It is still pretty much unknown at this point whether the adulterant is mineral oil, vegetable oil, or even vitamin E acetate as some reports are suggesting. But the reason lipoid pneumonia is suspected is because during a bronchoalveolar lavage — a procedure in which cells are collected from the lung by washing them back with saline under the guidance of a flexible camera and a suction tool — physicians discovered macrophage immune cells that consumed enough oil to stain red with a special dye. It still remains to be seen whether this is because of oil that was inhaled from the black market THC vapes or because vaping damaged the surfactant of the lung, which would allow the macrophages to consume the oils within the lung itself. Suffice it to say, we are all still trying to determine the cause, probably in the same way doctors in the 1920s may have been perplexed by people coming in with a variety of illnesses after making moonshine in the radiators of their own cars.

While using deaths caused by black market vapes to scapegoat the entire e-cigarette industry is unethical, the situation is complex because the vaping industry is guilty of its own terrible misdeeds. Companies like Juul, one of the most popular e-cigarette makers in the US, used deceptive marketing practices to target teens and schoolchildren. Juul even sent company representatives to schools and youth camps, sometimes without the teacher in the room, to promote vaping with enticing flavors like mango, mint, and cucumber.

Since the developing teenage brain is especially vulnerable to addictive behaviors and nicotine, tobacco companies like Altria, which owns a 35 per cent stake in Juul, appear to have hedged their bets with e-cigarettes to get a whole new generation hooked on nicotine — presumably make up for all the customers they lost from, you know, dying from tobacco. So instead of just serving as a harm reduction tool to cajole smokers to quit tobacco, vaping has now made nicotine “cool” again, or as cool as a cucumber flavor to entice kids.

Vaping has emerged as the fastest growing epidemic among teens in schools, who would have never taken up smoking yet are now new users of e-cigarettes. According to the National Youth Tobacco Study, more than 3.6 million middle and high schoolers used e-cigarettes in 2018, which is up more than double from 1.5 million in 2017. Unfortunately, many kids believe that e-cigarettes are harmless compared to smoking, which contributes to this massive epidemic. 

Yet this serious epidemic of teen vaping, which must be addressed, has nothing to do with the mysterious vaping injuries and deaths from black market THC vapes. Conflating the two is not only dishonest given the available evidence, but it is also harmful for patients.

In essence, there are three main issues going on simultaneously. First, there is a plague of tobacco smoking that claims the most lives by far and is the most clear and present danger to public health. Second, there is a growing epidemic of teen vaping that is getting a whole new generation addicted to nicotine. Third, there are people falling deathly ill because of black market THC vapes. All three problems can be solved if we tackle them separately, without fear-mongering and manipulating the truth. 

When it comes to smoking, e-cigarettes can be a powerful harm reduction tool to get tobacco users to quit their deadly vice. According to a large randomized trial published in the New England Journal of Medicine, e-cigarettes are more effective for smoking cessation than nicotine replacement therapy. Telling vapers to go back to smoking, or convincing smokers to keep smoking and not even give vaping a chance, causes great harm to society and must stop immediately. We should promote all ways possible to get smokers to quit or switch to less harmful methods of nicotine consumption. 

When it comes to the teen vaping epidemic, the government needs to crack down on deceptive marketing practices targeting children in schools. While adults enjoy flavors that do not remind them of tobacco, there has to be a balance here such that companies are not enticing children to start vaping pods that taste like mango or cotton candy. Even Juul seems to have acknowledged this by recently announcing that it will stop selling all flavored e-cigarettes in the United States, including “mango, creme, fruit, and cucumber,” ahead of a likely FDA ban.

At the same time, it is unreasonable and even dangerous for local governments to outright ban all e-cigarette products across the board. This may lead current vapers to go back to smoking, including the millions of teens who are already unfortunately addicted to nicotine. It may also lead to the rise of black market products for nicotine vaping, which would have deadly consequences.

Finally, when it comes to the black market THC vapes that have likely caused the mysterious lung injuries that brought the entire issue of vaping to the forefront of the news, the solution here is perhaps the simplest of all. There is no medical or scientific reason for marijuana to be illegal while far more deadly and addictive drugs like alcohol and tobacco are sold at the front counter. In my opinion, the only reason is racism.

When a large influx of Mexican immigrants came to the United States between 1910 to 1920 to escape the Mexican Civil War, they introduced marijuana to many Americans. Then in the 1930s, the head of the Federal Bureau of Narcotics, Henry Anslinger, waged a war against marijuana and demonized the drug as being associated with “degenerate races.” He helped pass the Marijuana Tax Act of 1937, which outlawed the drug nationally.

Well, it’s 2019 and it is way past time we heed facts and evidence over fear-mongering. Unlike alcohol and tobacco, not a single person in the history of all of human civilization has ever died from a marijuana overdose. It has therapeutic uses as well, including treating rare seizure disorders like Lennox-Gastaut and Dravet syndrome.

Moreover, more than 70 people, mostly of color, are serving life in prison for non-violent marijuana crimes while former Speaker of the House John Boehner gets rich selling it on an industrial scale. As an American doctor, I emphatically believe that in order to save lives, to prevent black market vaping injuries, and to even promote justice by mitigating the terrible scourge of mass incarceration, we must legalize weed. 

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