Angela Dearinger is justifiably worried about the prevalence of tobacco use in her state and region. Dearinger is Kentucky’s public health commissioner, and one in four adults in central Appalachia reports being a smoker. The national rate is 16.3 percent. 

In a study released this past spring, researchers from East Tennessee State University and NORC at the University of Chicago reported that deaths from heart disease, cancer and chronic lower respiratory disease – three of the four leading causes of death in the U.S. – occur more frequently in Appalachia than in the rest of the country. The study pointed to smoking as a key contributing factor. 

Kentucky, Tennessee and West Virginia are among the five states with the highest smoking rates in the country, but it was the region’s young people specifically who were on Dearinger’s mind when she spoke recently to a gathering of health care professionals hosted by the University of Kentucky’s Center of Excellence in Rural Health in Hazard. Centers for Disease Control and Prevention statistics indicate that Kentucky and West Virginia have the nation’s two highest youth smoking rates.

Dearinger shared her deep concern with these statistics. Her focus, though, was e-cigarettes, citing a nationwide spike in their use among youth, some as young as the sixth grade. She referenced the reported dangers of e-cigarettes and the fact that for many, they’re an introduction to a range of tobacco products.

Hadii Mamudu is an associate professor in the East Tennessee State University College of Public Health’s Department of Health Services Management and Policy. He was co-author of a 2016 school-based study in rural northeast Tennessee in which 11 percent of participants were found to be using e-cigarettes. Thirty-five percent reported having tried them.

While many adults turn to e-cigarettes as a means to quit smoking, Mamudu says that is not the case among youth. “There is no evidence that they are using e-cigarettes as a quitting device,” he said. In fact, his school-based study indicated that more than half of current e-cigarette users also smoked cigarettes.

Mamudu argues that a growing body of evidence documents the immediate and long-term risks of e-cigarettes.  

In December, the Food and Drug Administration announced that it was raising the federal minimum age to buy tobacco products from 18 to 21. That includes e-cigarettes.

Raising the legal age is a good move, Mamudu said. It “will make a significant impact on access to nicotine products. But does this change my view about the regulation of vaping? My answer is an emphatic ‘no.’” 

The Argument Against Banning 

The CDC reports that as of Jan. 7, there had been 57 e-cigarette-associated deaths across the country. More than 2,500 people had been hospitalized.

Symptoms reported include significant breathing difficulties, heavy coughing, vomiting, nausea and diarrhea. A Mayo Clinic study found that lung damage in some cases resembled chemical burns.

In November, the U.S. Attorney’s Office for the Northern District of West Virginia issued a warning to parents after two students overdosed at Morgantown High School, in Morgantown, West Virginia, on heroin-laced vape pens.

Many of the e-cigarette-related injuries have been associated with people vaping with THC – the source of the high from marijuana smoking – most particularly from products that were bought on the street or that came from acquaintances. 

But Dearinger pointed out that 45 percent of cases of reported injuries were from products that contained both nicotine and THC and 17 percent were nicotine only.

In early January, the FDA issued a ban on the sale of fruit-, mint- and candy-flavored e-cigarette products – which are popular with high school students – but not menthol and tobacco-flavored products. A number of states and counties had previously issued bans or warnings on flavored products.  

In September, when the Trump administration announced that it would issue a ban on flavored e-cigarettes, including menthol, the president was reportedly warned that a ban would not be well received by his base, perhaps even posing a threat to his re-election prospects.

There has, in fact, been a significant backlash to the restriction and potential widespread banning of these products. 

Sally Satel, a lecturer in psychology at the Yale University School of Medicine and a scholar at the American Enterprise Institute, said in testimony to a U.S. House of Representatives subcommittee that the lung-injury issue “is a story of the dangers of the black market, not of vaping.” 

Warning smokers “in a blanket manner not to vape is a hazard to smokers who have already switched to e-cigarettes and now risk a return to smoking combustible cigarettes,” Satel said. 

“The key lesson here is that the tragic cases of lung injury and death are completely separate from the commercially sold vaping products intended to help smokers relinquish cigarettes,” she continued. “Risk communication and policies targeted at THC, not global warnings against vaping, are needed.”

“The central fact,” Satel said, “is that vaping is much less hazardous than smoking.”

Qualified Advocacy 

In her comments, Satel acknowledged that comparing the risks of vaping to smoking is a relative statement. For Hadii Mamudu, the weighing of those risks is like deciding whether to jump from the 20th or 40th floor of a building.

Satel urged Congress not to “allow the intense focus on teen use – warranted though it is – to divert almost all attention from the benefits of vaping for adult smokers who are dying at the rate of 480,000 per year.”

Mamudu is not unsympathetic to that argument. In fact, he recognizes there’s merit in advocating for e-cigarettes as smoking-cessation devices for some adults, but not at the population level. 

“As a population-based, wholesale promotion, I’m not for it,” he said. “As a population-based tool, I think the harm is greater than the benefit.” 

Perhaps the answer, he said, is to make the products available on a prescription basis.

“There is no silver bullet to address this vaping issue,” Mamudu said. Rather, “there is strong support for a comprehensive approach that is similar to tobacco control.” Such an approach would include regulations, restrictions on advertising and promotion, bans in public spaces and evidence-based research on the efficacy of e-cigarettes in smoking cessation.