Medical Examiner

What the E-Cigarette Bans Get Wrong

More people are likely to die due to lack of access to e-cigarettes than will die from vaping.

Photo illustration of a carton of cigarettes.
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It’s well-established that humans are subject to various biases when weighing risks. We tend to overlook familiar, yet significant, dangers, while reacting strongly to dramatic or unfamiliar perils that are prominent in the news or make us feel dread. Most of us know, for example, that commercial air travel is much safer than driving. It’s been more than a decade since the last fatal airline crash in the United States, while more than 30,000 Americans die each year in traffic accidents. Yet, many of us feel anxious about flying despite driving cars without a moment’s hesitation.

A striking consequence of this discrepancy followed the Sept. 11, 2001, terror attacks. The visceral fear inspired by that event caused people to avoid flying in favor of driving. The cost and hassle of new security measures likely exacerbated this effect. Researchers estimate that in the months after the attacks, this substitution of a risky activity for an objectively safer one resulted in hundreds of excess traffic fatalities. “Terrorists can strike twice,” concluded risk analysts Wolfgang Gaissmaier and Gerd Gigerenzer, “first, by directly killing people, and second, through dangerous behaviors induced by fears in people’s minds.”

We are likely to see something similar happen with e-cigarettes. Reports of so-called vaping deaths have dominated headlines for months, provoking health groups, regulators, and legislators to call for bans on the products. It has been clear for much of this time, though, that the primary and perhaps only culprit is contaminants in mostly black-market cannabis cartridges. Testing by the Centers for Disease Control and Prevention found vitamin E acetate, a substance used to dilute some THC oils, in lung fluid samples from all of the patients it tested. Before taking drastic action against vaping in general, then, it’s worth asking whether panicked responses to this frightening lung illness might end up doing more harm than good.

Economists observed a similar effect after the Fukushima Daiichi nuclear disaster. Prior to the incident, Japan was the world’s third-largest consumer of nuclear energy. But the sudden fear of disaster led to a complete shutdown of the country’s nuclear generators and a transition to burning fossil fuels. In the end, the switch not only increased air pollution and carbon emissions, it also substantially raised the cost of power. As a result, residents were less able to afford sufficient heating to protect themselves during extreme winter cold. In a working paper from the National Bureau of Economic Research, economists estimate that this led to more than 1,200 excess deaths from 2011–14, potentially dwarfing the mortality associated with the actual event.

In a paper from 2002, psychologists Paul Slovic and Elke Weber describe these sorts of reactions to frightening events as the “social amplification of risk.” They note that when an unexpected danger arises, “the adverse impacts … sometimes extend far beyond the direct damages to victims and property and may result in massive indirect impacts such as litigation against a company or loss of sales, increased regulation of an industry, and so on. … Thus, the event can be thought of as a stone dropped in a pond. The ripples spread outward, encompassing first the directly affected victims, then the responsible company or agency, and, in the extreme, reaching other companies, agencies, or industries.” Through this process of social amplification, relatively minor risks can result in disproportionate or mistargeted responses.

It’s an apt description of the current panic over lung illnesses, in which contaminants in the black market THC trade have provided cover for crackdowns on the legal market for nicotine e-cigarettes. A Google News search for “vaping illness” yields more than 130,000 results, many of which fail to clearly communicate the type of products implicated in the outbreak. Others dramatically overstate the danger. A report in Wisconsin, for example, warns that “a single puff” of vapor could be fatal. The entire vaping industry, the survival of which has long been tenuous in the face of restrictive regulation and ideological opposition to nicotine use, could be existentially threatened by fearful responses to such coverage.

This lung illness is legitimately scary and in urgent need of continued investigation and prevention. But we should keep the danger in perspective. Total deaths attributed to it currently number 42. The CDC estimates that 480,000 annual deaths in the United States are associated with smoking. That means around 30 times more Americans die from smoking-related diseases every single day than have died from the entire run of the so-called vaping illness. We become tragically inured to these deaths because they are part of a familiar landscape. Vaping is unfamiliar, so we react with alarm to any potential risk. The barrage of news stories on the topic make it difficult to respond rationally.

At the beginning of this year in an article for Slate, I warned that the moral panic over vaping may recapitulate the errors of Prohibition and the war on drugs. Unfortunately, there are now signs that this is the direction in which we are headed. In Michigan, police went store to store enforcing a ban on flavored vaping products and an emergency order from Gov. Gretchen Whitmer imposed penalties of up to six months in prison for violators. In Massachusetts, detectives surveilled a vape store, searched a driver seen leaving the location, and seized his device as evidence of illegal sales. Lawmakers there are currently working on a bill that will ban all flavored vaping products.

Such irrational responses put even more lives at risk. Lawmakers and regulators face incentives to take an extremely precautious approach, seeking to minimize all possibility of danger. But as the Royal College of Physicians argues in a thorough report on tobacco harm reduction, excessive risk aversion can itself be harmful: “If this approach also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking.”

Much like the substitution of driving for flying after 9/11 or fossil fuels for nuclear power after Fukushima, the substitution of cigarettes for vaping among current or even potential vapers would have lethal consequences. Modeling by public health researchers suggests that widespread switching from smoking to vaping has the potential to prevent more than 6 million premature deaths. But public perception lags behind: Americans increasingly disagree that vaping is less dangerous than smoking cigarettes, and there are anecdotal reports of vapers going back to smoking. Shortsighted policies advocated by anti-smoking groups make this perverse outcome increasingly likely.

Flavor bans make e-cigarettes less appealing to current smokers; bans on internet sales deprive access to smokers in rural areas; alarmist messaging makes smokers less likely to switch; and, of course, outright bans on e-cigarettes, such as those enacted in San Francisco or Massachusetts, completely deny smokers the opportunity to switch to a safer product. These fear-driven responses also threaten the freedoms of consenting adults. Security expert Bruce Schneier noted in 2013 that in response to frightening events, we “tend to fixate on a particular risk and then do everything we can to mitigate it, including giving up our freedoms and liberties.” He wasn’t discussing e-cigarettes, but the point strikingly applies to the current situation.

None of this befits a free society. Although the vaping community dodged a bullet with the Trump administration’s reversal on a nationwide flavor ban, fear-based responses from other health agencies, lawmakers, and anti-smoking groups still endanger the cause of tobacco harm reduction. While reasonable steps should be taken to combat youth use of e-cigarettes, we should begin from the liberal presumption that adults are sovereign over their own bodies. Striking the right balance requires carefully weighing risks and refusing to give into panic. If we get that balance wrong, don’t be surprised if, a few years from now, we see research explaining how irrational responses to this year’s mysterious lung illness led to more preventable deaths than the illness itself.