How EVALI, and the way it was reported, damaged perceptions of vaping

Many smokers in England believe that vaping is at least as harmful as combustible cigarettes, despite e-cigarettes’ lower production of toxicants and carcinogens.

Research by University College London, London, UK and Spectrum Research Consortium UK, a multi-university, multi-agency research group focused on the commercial determinants of health and health inequalities, suggests that smokers may be dissuaded from switching, even though public authorities such as the US Food and Drug Administration (FDA) and Public Health England (PHE) accept that vaping is likely much less risky to health than traditional cigarettes.

The study examined the connection of the US outbreak of vaping-associated lung injury (EVALI) in summer and autumn 2019 with the perception of risk of e-cigarettes compared with cigarettes. Although there has been no similar lung disease outbreak in the UK, the global news coverage nevertheless had a dramatic impact on risk perception.

Researchers surveyed UK smokers before and after the outbreak to identify changes in perception. After the outbreak, in the final quarter of 2019, the percentage of individuals who perceived e-cigarettes as less harmful than cigarette smoking fell to its lowest recorded point, while the percentage perceiving it as more harmful increased by more than a third.


Discouraging switching


The researchers do not claim that there will be a definite cost to public health, but worry about potential behaviour changes with public health consequences.

Smokers may be deterred from switching from cigarettes to e-cigarettes. People who had previously quit smoking cigarettes through vaping may return to combustibles.

Although research into the outbreak is on-going, evidence suggests that the occurrence of EVALI may be associated with inhaling vitamin E acetate used as an additive in THC (tetrahydrocannabinol) vaping devices.

The US Centers for Disease Control and Prevention (CDC)’s Morbidity and Mortality Weekly Report on 1st November 2019 investigated patient characteristics and the substances used in e-cigarettes or vaping products: 86% reported use of products containing THC. The true number could be higher, as data on substances was self-reported and social desirability bias may have prevented disclosure of the use of THC. But because the research is on-going, no single compound or ingredient can confidently be identified as the sole cause of EVALI.

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    CDC’s cautious approach


    The CDC has recommended that people refrain from the use of e-cigarettes and vaping fluid that contains THC. Exercising caution, the CDC also recommended that while the specific compound causing the lung injury is unknown, people may want to refrain from the use of all vaping products.

    The CDC’s recommendations were widely published, but largely unreported on the implication of specific compounds, the vitamin E acetate used in THC vaping devices being a strong candidate as a cause of EVALI.

    A further recent study published by the Society for the Study of Addiction (SSA), strongly indicates that the US EVALI outbreak resulted from locally distributed e-liquids or additives prevalent in the area affected, rather than either e-cigarette use or THC.


    What This Means: Reporting of the US EVALI outbreak clearly damaged public perception of vaping generally, not merely that of additives that are the likeliest cause of the disease. Researchers believe clearer public health messages could counter this false perception about the relative harm of different nicotine products.

    The study, “Association of the US outbreak of vaping associated lung injury with perceived harm of e-cigarettes compared with cigarettes”, was published by the Jama Network. The lead author was Harry Tattan-Birch.

    – Catherine Maclean ECigIntelligence science writer


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    This article was written by one of ECigIntelligence’s international correspondents. We currently employ more than 40 reporters around the world to cover individual vaping markets. For a full list, please see our Who We Are page.

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