G Kumar’s vaping addiction peaked in college at the University of Colorado, when flavored, disposable vapes were taking off.

“I’d go through, let’s say, 1,200 puffs in a week,” Kumar said.

Vaping became a crutch for them. Like losing a cellphone, losing a vape pen would set off a mad scramble.

“It needs to be right next to my head when I fall asleep at night, and then in the morning, I have to thrash through the sheets and pick it up and find it,” Kumar recalled.

They got sick often, including catching covid-19 — and vaping through all of it.

Kumar, now 24, eventually quit. But many of their generation can’t shake the habit.

“Everyone knows it’s not good for you and everyone wants to stop,” said Jacob Garza, a University of Colorado student who worked to raise awareness about substance use as part of the school’s health promotion program.

“But at this point, doing it all these years … it’s just second nature now,” he said.

Marketing by e-cigarette companies, touting the allure of fruity or candy-like flavors and names, led many teens to try vaping. As more high schoolers and younger kids experimented with e-cigarettes, physicians and it could lead to widespread addiction, creating a “Generation Vape.”

Research has shown to the brains of young people.

New data on substance use among adults ages 18-24 suggests that many former teen vapers remain e-cigarette users. National vaping rates for young adults increased from to .

It’s not surprising that many of them start in high school for social reasons, for all sorts of reasons,” said Delaney Ruston, a primary care physician and documentary filmmaker. “And many of them now — we’re seeing this — have continued to college and beyond.”

Her is “Screenagers Under the Influence: Addressing Vaping, Drugs & Alcohol in the Digital Age.”

In Colorado, the share of those 18 to 24 who regularly vaped rose by about 61% from 2020 to 2022 — to nearly a quarter of that age group.

“That’s an astounding increase in just two years,” Ruston said.

Trends in that state are worth noting because, before the pandemic, in youth vaping among high school students, surpassing 36 other states surveyed.

Nationally, vaping rates among high schoolers dropped from to , according to the Annual National Youth Tobacco Survey. But for many young people who started vaping at the height of the trend, a habit was set.

At Children’s Hospital Colorado, pediatric pulmonologist displayed on her screen a clouded X-ray of the lung of a young adult damaged by vaping.

For years, doctors like her and public health experts wondered about the potentially on pre-adult bodies and brains — especially the big risk of addiction.

“I think, unfortunately, those lessons that we were worried we were going to be learning, we’re learning,” said De Keyser, an associate professor of pediatrics in the .

“We’re seeing increases in those young adults. They weren’t able to stop.”

It’s no coincidence the vaping rates soared during the pandemic, according to several public health experts.

For the past couple of years, undergraduates have talked about the challenges of isolation and using more substances, said Alyssa Wright, who manages early intervention health promotion programs at CU-Boulder.

“Just being home, being bored, being a little bit anxious, not knowing what’s happening in the world,” Wright said. “We don’t have that social connection, and it feels like people are still even trying to catch up from that experience.”

Other factors driving addiction are the high nicotine levels in vaping devices, and “stealth culture,” said Chris Lord, CU-Boulder’s associate director of the .

“The products they were using had than previous vapes had,” he said. “So getting hooked on that was … almost impossible to avoid.”

By “stealth culture,” Lord means that vaping is exciting, something forbidden and secret. “As an adolescent, our brains are kind of wired that way, a lot of us,” Lord said.

All over the U.S., state and local governments have filed suits against , alleging the company misrepresented the health risks of its products.

The lawsuits argued that Juul became a top e-cigarette company by aggressively marketing directly to kids, who then spread the word themselves by posting to social media sites like YouTube, Instagram, and TikTok.

“What vaping has done, getting high schoolers, in some cases even middle schoolers, hooked on vaping, is now playing out,” said .

Juul agreed to pay . The company did not respond to requests for comment on this article.

R.J. Reynolds, which , Vuse, sent this statement: “We steer clear of youth enticing flavors, such as bubble gum and cotton candy, providing a stark juxtaposition to illicit disposable vapor products.”

Other , like Esco Bar, Elf Bar, Breeze Smoke, and Puff Bar, didn’t respond to requests for comment.

“If we lived in an ideal world, adults would reach the age of 24 without ever having experimented with adult substances. In reality, young adults experiment,” said Greg Conley, director of legislative and external affairs with American Vapor Manufacturers. “This predates the advent of nicotine vaping.”

The FDA banned flavored vape cartridges in 2020 to crack down on marketing to minors, but the .

Joe Miklosi, a consultant to the Rocky Mountain Smoke-Free Alliance, a trade group for vape shops, contends the shops are not driving vaping rates among young adults in Colorado. “We keep demographic data in our 125 stores. Our average age [of customers] is 42,” he said.

He has spoken with thousands of consumers who say vaping helped them quit smoking cigarettes, he said. Vape shops sell products to help adult smokers quit, Miklosi said.

Colorado statistics belie that claim, according to longtime tobacco researcher . The data is “completely inconsistent with the argument that most e-cigarette use is adult smokers trying to use them to quit,” said Glantz, the former director of the at the University of California-San Francisco.

For recent college graduate G Kumar, now a rock climber, the impetus to quit vaping was more ecological than health-related. They said they were turned off by the amount of trash generated from used vape devices and the amount of money they were spending.

Kumar got help from cessation literature and quitting aids from the university’s health promotion program, including boxes of eucalyptus-flavored toothpicks, which tasted awful but provided a distraction and helped with oral cravings.

It took a while and a lot of willpower to overcome the intense psychological cravings.

“The fact that I could just gnaw on toothpicks for weeks on end was, I think, what kept me sane,” Kumar said.

This article is from a partnership that includes , , and ºÚÁϳԹÏÍø News.

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In the city of Vallejo on the northeastern edge of San Pablo Bay, Council member Peter Bregenzer is leading an effort to crack down on smoke shops, which he says make it much too easy for children to smoke and vape. In Oakland, Council member Dan Kalb is weighing a new ordinance that would extend smoking bans to all apartment and condominium buildings, as well as bar patios.

The advocacy group , following a successful push in nearby Concord, is among the backers of the Vallejo ordinance, and is also pushing for San Francisco and Oakland to ban outdoor smoking at bars.

Joseph Hayden, a Vallejo resident and a volunteer with LGBTQ Minus Tobacco, said the time is right for the city to act.

“Some people have told me they’d ban it all — tobacco sales — if they could, like Manhattan Beach and Beverly Hills,” said Hayden, who is also a volunteer with Tobacco Free Solano. “We want to be sure this [ordinance] has teeth.”

Christina Lee, a spokesperson for Vallejo, said the City Council would likely vote on the measure this summer after a public notice period. The city held an informational workshop for tobacco retailers in February, notifying them by email, but no one attended, she added.

The National Association of Tobacco Outlets did not respond to requests for comment from ºÚÁϳԹÏÍø News.

California was the first state to ban smoking in all indoor public spaces and offices, in 1995, and later it raised the legal age for tobacco purchases to 21 from 18. In 2022, the state’s voters passed affirming a ban on flavored vapes, menthol cigarettes, and other products.

But antismoking activists want to see more action at the local level, especially when it comes to keeping cigarettes and vapes out of the hands of children. A strong push is coming from anti-tobacco campaigners in the LGBTQ+ community, which has higher rates of smoking than the population at large and historically has been a target of tobacco industry marketing.

One sore point is the notorious 1995 R.J. Reynolds effort called (Sub-Culture Urban Marketing) campaign, which was aimed at selling more cigarettes in San Francisco’s Castro district, a largely gay neighborhood, and in the low-income Tenderloin district.

The FDA has long recognized that certain populations, including the LGBTQ+ community, are more likely to smoke than others and has tailored public health messaging to those groups. From 2016 to 2020, the agency’s Center for Tobacco Products ran a that featured drag queens from the reality series “RuPaul’s Drag Race.”

However, in the , 11.4% of LGBTQ+ respondents reported current tobacco use, well above the 6.4% reported by non-LGBTQ+ respondents.

Research suggests that the pressures associated with belonging to a group that faces discrimination are likely a cause of the high smoking rates. A review of smoking studies in the journal recently found that “internalized queerphobia,” perceived stigma, and prejudice all increased the likelihood of cigarette use.

Smoking can also be caught up in the identity of LGBTQ+ people who associate it with the rejection of conventional mores, said Brian Davis, project director for LGBTQ Minus Tobacco.

“Queer young people may even connect queerness and smoking,” he said.

In Vallejo, Bregenzer, who is gay and said smoking killed his father, is motivated partly by a desire to protect the LGBTQ+ community. He’s also concerned about youth smoking, especially flavored vapes, which appeal to children and are illegal to sell in California but can often be found in smoke shops.

“Youth want to feel cool and fit in, and cherry- or grape-flavored tobacco products may mask the taste they don’t like,” he said.

Bregenzer’s proposed Tobacco Retail License ordinance would ban the sale of all vapes and all flavored products not covered by the state law, as well as 99-cent cigars. It would also require tobacco retailers to pay a yearly fee to be used for youth decoy operations and other enforcement mechanisms.

Vallejo’s smoking problem is apparent in the schools. Heena Bharti, a 10th grader who does not identify as LGBTQ+, said she’s seen vape smoke rise in the back of her classroom. She deftly brushes off pressure to vape with a “No thanks, I’m OK.”

Almost 31% of public schools in Vallejo are within 1,000 feet of a tobacco retailer, according to the February 2024 . The 2021-22 reported that 37% of Vallejo City Unified School District juniors said getting cigarettes was fairly or very easy, and 60% said that was true of e-cigarettes.

Bar patios are another frontier for local activists. Davis said more than 100 California cities, including Vallejo, already require bar patios to be smoke-free, and a top priority for his organization is to have San Francisco and Oakland join that group of cities.

“The tobacco industry uses bars to target queer people by offering event sponsorships, bar promotions, giveaways, coupons, and advertising,” Davis said.

Not everyone in the LGBTQ+ community is on board with the new rules. Tony Jasinski, board president of the , called Davis’ push to make bar patios smoke-free a “nanny-state” proposal that didn’t consider the effect on businesses in a in December.

Jasinski told ºÚÁϳԹÏÍø News that such bans drive tourists away and send the message that “we are over-legislated against choice.”

Kalb, the Oakland Council member, doesn’t see it that way.

“It’s weird we already don’t allow smoking in outdoor seating areas of restaurants, but somehow if you’re just drinking, it’s OK?” he said.

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

A registered nurse who works in New Jersey’s Matawan-Aberdeen Regional School District reacted on X, formerly known as Twitter, to ºÚÁϳԹÏÍø News’ investigative collaboration with Cox Media Group on the federal government’s attempt to claw back money it has overpaid to Social Security beneficiaries: “Social Security Overpays Billions to People, Many on Disability. Then It Demands the Money Back” (Sept. 15).

— Sheila Caldwell, Aberdeen, New Jersey

A law professor at the S.J. Quinney College of Law at the University of Utah also chimed in on X:

Important
exposé on Social Security making errors and sending people ludicrous bills to to recover overpayments. One disabled woman got a bill for $60,175.90 out of the blue.

The agency suffers from underfunding/understaffing

— Daniel G. Aaron, MD, JD (@MedlawDan)

— Daniel G. Aaron, Salt Lake City

For Shame, UnitedHealthcare

Thank you for shining a light on one of the most infuriating insurance barriers in all of medicine: prior authorization (“Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials,” Aug. 23).

During the pandemic, many people skipped or could not access routine medical care such as colonoscopies and endoscopies. Research has long shown that these services are underutilized, especially among communities of color, which is one reason for continued disparities in colorectal cancer and other gastrointestinal diseases.

As the demand for routine diagnostic and surveillance procedures grows, it is critical to ensure that patients are not caught up in bureaucratic red tape. Unfortunately, the nation’s largest and most profitable insurer, UnitedHealthcare, is slowly, quietly working to expand prior authorization to these key forms of gastrointestinal care.

While UHC publicly pledged to slash prior authorization, we must judge them by their actions, not their words. Since UHC made that promise this spring — a move welcomed by doctors and patients across the country — the insurer also announced troubling new prior authorization requirements for colonoscopies and endoscopies for its 27 million commercial beneficiaries. The insurer planned to begin implementing prior authorization for these vital procedures starting June 1 but temporarily halted the plan after major outcry from patients and gastroenterologists.

Yet, the threat lingers. Right now, UHC is asking doctors to participate in a burdensome “Advanced Notification program,” which forces physicians to submit all kinds of data that the insurer will use to inform its planned “Gold Card” prior authorization program in 2024.

Physicians see through this ruse. While UHC claims no patients are being denied the colonoscopies and endoscopies that could help save their lives, the administrative burden Advanced Notification causes is clogging already backlogged offices, especially small practices. Even worse, the gastroenterological community fears that millions of patients may face UHC’s prior authorization requirements in a matter of months — yet the insurer has failed to coordinate with specialty societies or transparently communicate how the program will operate or how UHC will ensure patient care is not disrupted.

This issue affects all of us. If UHC is allowed to deny or delay colonoscopies and endoscopies, where will it end? Diagnostic mammograms? Pap smears? Lung cancer screenings? And will other insurers follow suit with equally oppressive prior authorization policies?

UHC must immediately reverse course on its alarming policies to ensure streamlined access to care. In the meantime, gastroenterologists will continue to hold the line for our patients.

— Lawrence Kim, vice president of the American Gastroenterological Association, Lone Tree, Colorado

The branding director for Norwood, a health care staffing and consulting company in Texas, posted on X that publicly shaming insurers may prove a smart strategy.

Good; shameful practices deserve public shaming: Doctors and Patients Try to Shame Insurers Online to Reverse Prior Authorization Denials via

— Brian Murphy (@NorwoodCDI)

— Brian Murphy, Austin, Texas

Reaction was also robust on Threads:

How New York Is Tackling Tobacco Use Among Youths

I just read Liz Szabo’s piece on child nicotine poisonings (“Doctors Sound Alarm About Child Nicotine Poisoning as Vapes Flood the US Market,” Aug. 3). The reporting illuminated a crucial yet lesser-known issue regarding the harms of these e-liquids. The response does call for a combined public health effort, so I wanted to share further information regarding New York state policy (mentioned in the piece) that has shown to be successful in reducing the sale and use of vapes and traditional, combustible cigarettes. This policy-level intervention’s results imply that fewer young children are being exposed to/have access to these products based on decreased rates of smoking and vaping use and initiation among older siblings or adults around them. I hope this information proves useful to your national audience who may consider these policies in the context of their state’s.

The New York State Department of Health that indicate that the current tobacco control policies adopted in the state have helped effectively reduce tobacco use and initiation, including smoking and vaping. The evidence-based approaches bolstered ongoing decreases in youth vaping rates; between 2018 and 2022, rates declined by about 32%. Youth tobacco use (of any tobacco product) also declined by 32%, from 30.6% in 2018 to 20.8% in 2022. This significant decline brings New York closer to achieving the goal of decreasing high school youth tobacco use to 19.7% by 2024.

While this is great progress, tobacco still is the No. 1 cause of preventable disease in the United States — it is estimated that it kills 480,000 adults in the U.S. every year — and there are still issues with regulation and a lack of protective packaging on vapes.

works with health care organizations in New York City to ensure they effectively screen and treat their patients for tobacco use.

— Avani B. Ansari, MPH, CHES, project coordinator for NYC Treats Tobacco, New York City

An organization that advocates for policies promoting opportunities and wellness for children posted this on X:

Thousands of kids a year are exposed to the liquid nicotine in e-cigarettes, also known as vapes. For a toddler, even a few drops can be fatal. Doctors sound alarm about child nicotine poisoning as vapes flood the US market:

— KY Youth Advocates (@KYYouth)

— Kentucky Youth Advocates, Jeffersontown, Kentucky

And a Georgia state representative shared her two cents on X regarding Liz Szabo’s previous coverage on youth vaping:

Youth vaping is on the rise, with the industry marketing products blatantly targeted to kids + teens.

The unregulated nicotine in e-cigs (⬆️ 76% over 5y) can addict kids in just days.

My bills and aim to study + disincentivize youth vaping.

— Dr. Michelle Au (@AuforGA)

— Michelle Au, Johns Creek, Georgia

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Kids can also become dizzy, lose consciousness, and suffer dangerous drops in blood pressure. In the most severe case he’s seen, doctors put another boy on a ventilator in the intensive care unit because he couldn’t breathe, said Marino, of Case Western Reserve University School of Medicine.

Thousands of kids a year are in e-cigarettes, also known as vapes. For a toddler, even a few drops can be fatal.

Cases of vaping-related nicotine exposure reported to poison centers in 2022 — despite a , the Child Nicotine Poisoning Prevention Act, that requires child-resistant packaging on bottles of vaping liquid. In what doctors call a major oversight, the law doesn’t require protective packaging on devices themselves.

Refillable vapes are designed to hold liquid nicotine in a central reservoir, making them dangerous to kids, Marino said. Even vapes that appear more child-resistant — because their nicotine is — present a risk, because the cartridges can be pried open. And some disposable e-cigarettes, now the top-selling type on the market, allow users to take and as multiple packs of cigarettes.

Many e-cigarettes and liquids seem , with pastel packages, names such as “,” and flavors such as bubble gum and blue raspberry. That makes vapes far more tempting — and hazardous — than traditional cigarettes, which have lower doses of nicotine and a bitter taste that often prompts children to quickly spit them out, said Diane Calello, the executive and medical director of the New Jersey Poison Information and Education System.

“Nicotine liquid is an accident waiting to happen,” Calello said. “It smells good and it’s highly concentrated.”

Sen. Richard Blumenthal (D-Conn.), who co-sponsored the 2016 legislation, said he would push to expand the childproof packaging requirement to disposable and pod-based e-cigarettes.

“Every day that FDA allows flavored e-cigarette products to remain on the market is another day that children can be enticed by these dangerous, and sometimes deadly, products,” he said.

Although the FDA declined to comment for this article, on Aug. 2 the agency included a special feature about in children in its “CTP Connect” newsletter.

The number of reports to poison control centers about e-cigarettes has more than doubled since 2018, according to an FDA analysis. Poison control centers reported more than 7,000 vaping-related exposures in people of all ages from April 1, 2022, to March 31, 2023.

According to the FDA, 43 of those exposures resulted in hospitalization and an additional 582 in other medical treatment. About half of poison center reports had no information about whether patients needed medical care.

Nearly 90% of exposures involved children under 5. Authors of the report say their numbers likely underestimate the problem, given that poison control centers aren’t contacted in every case.

A from vaping-related nicotine poisoning in 2014. The new FDA report also mentions the apparent suicide of an adult via e-cigarette poisoning.

A spokesperson for the vaping industry said companies take safety seriously.

“All e-liquid bottles manufactured in the United States conform to U.S. law,” said April Meyers, the president of the board of directors and CEO of the Smoke-Free Alternatives Trade Association, which represents the vaping industry. “Not only are the caps child-resistant, but the flow of liquid is restricted so that only small amounts can be dispensed.”

Yet many vaping products are made outside the U.S., which has recently been flooded with illegal e-cigarettes, mostly from China.

The increasing number of nicotine exposures among kids — especially curious toddlers who put virtually everything they can grab into their mouths — likely reflects the sheer volume of e-cigarette sales, said Natalie Rine, the director of the Central Ohio Poison Center at Nationwide Children’s Hospital.

E-cigarette unit sales from January 2020 to December 2022, rising from 15.5 million every four weeks to 22.7 million, according to a report published by the Centers for Disease Control and Prevention.

“This isn’t something that parents see as a really big risk,” Marino said. “But with the popularity of e-cigarettes, the risk isn’t going away anytime soon.”

One effective strategy to reduce e-cigarette sales has been to ban flavored products. California, Massachusetts, New Jersey, New York, Rhode Island, and Washington, D.C., , while Utah and Maryland have banned some flavors. A study showed overall e-cigarette sales in states after flavor bans, compared with states that didn’t ban them.

Some doctors say the country needs to do more to protect children.

“If the numbers are rising, then the law ain’t working,” said Carl Baum, a professor of pediatrics and emergency medicine at Yale School of Medicine.

Pediatrician Gary Smith said the lack of child safety requirements for e-cigarette devices is a major problem. Refillable e-cigarettes are relatively easy for kids to open.

Although most poison control center reports don’t include brand information, disposable e-cigarettes — including Elfbar, Puff Bar, and Pop Vape — were some of the most common products mentioned in the FDA analysis. Elfbar is now known as EB Design.

Expanding the federal law to include devices would be “an important step,” said Smith, president of the Child Injury Prevention Alliance, an Ohio-based advocacy group that works to prevent injuries in children.

In addition, federal officials should limit the nicotine concentration in vape juices to make them less toxic, as well as ban candy-like flavors and colors on packaging, Smith said.

“The public health response should be comprehensive,” Smith said.

Kids have been known to pick up a vape and begin puffing, in imitation of their parents, Calello said.

Even if children don’t inhale the aerosol, sucking on a vape exposes their skin to nicotine, which can be absorbed into the bloodstream, said Robert Glatter, an assistant professor of emergency medicine at Lenox Hill Hospital in New York City. Glatter noted that e-cigarette liquids also , including arsenic and lead, which is toxic at any dose; carcinogens such as acetaldehyde and formaldehyde; and benzene, a volatile organic compound found in auto exhaust.

Fortunately, children who inhale nicotine get a much lower dose than those who ingest it, reducing the risk of serious harm, said Marc Auerbach, a professor of pediatric emergency medicine at Yale School of Medicine.

Only about 2% of exposures in the FDA study were recorded as having a moderate or major effect.

That may be because little kids who get into dangerous liquids — from vape juice to household cleaning products or gasoline — usually spill most of it, Baum said. “They often end up wearing it rather than swallowing it,” Baum said.

Although Stephen Thornton has seen a lot of children with nicotine exposure, he said, the human body has ways of protecting itself from toxic substances. “Fortunately, when kids do ingest these e-cig nicotine products, they self-decontaminate. They vomit — a lot — and this keeps the mortality rate very low, but these kids still often end up in emergency departments due to all the nausea and vomiting,” said Thornton, an emergency medicine physician and medical director of the Kansas Poison Control Center.

The FDA of young children to keep e-cigarettes and vaping liquid out of reach and in its original container.

For emergency assistance, call Poison Help at 800-222-1222 to speak with a poison expert, or visit poisonhelp.org for support and resources.

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Preserve all the rituals of smoking: Light up a cigarette, inhale the smoke, including the nasty stuff that can kill you, and exhale. But remove most of the nicotine, the chemical that makes tobacco so darn hard to quit, to help smokers smoke less.

The Food and Drug Administration has been for at least six years as one way to make it easier for smokers to cut back, if not quit entirely. Less than two years ago, it authorized 22nd Century Group, a publicly traded based in Buffalo, New York, to advertise its proprietary low-nicotine cigarettes as modified-risk tobacco products.

Now, the first authorized cigarettes with 95% less nicotine than traditional smokes are coming to California, Florida, and Texas in early July, after a year of test-marketing in Illinois and Colorado. It’s part of an aggressive rollout by 22nd Century that, by year’s end, could bring its products to 18 states — markets that together account for more than half of U.S. cigarette sales.

But anti-smoking groups oppose greenlighting 22nd Century’s products. Instead, they to expand on their original plan of setting a for all combustible cigarettes to make them minimally or nonaddictive. They expect the FDA to take the next step in that industrywide regulatory process as early as this fall.

“Unless and until there is a categorywide requirement that nicotine goes down to low, nonaddictive levels, this is not going to make a difference,” said Erika Sward, a spokesperson for the American Lung Association.

Major tobacco companies , , and did not respond to requests for comment.

Cigarette smoking is estimated to cause in the U.S., including from secondhand smoke, and contributes to tobacco use being the leading preventable cause of death nationally. In 2018, then-FDA Commissioner Scott Gottlieb wrote that setting a maximum nicotine level “could result in more than 8 million fewer tobacco-caused deaths through the end of the century – an undeniable public health benefit.”

The FDA reasoned that people would collectively smoke fewer cigarettes and have less exposure to the deadly toxins that are still present in low-nicotine cigarettes.

22nd Century says it used a patent-protected process to control nicotine biosynthesis in the tobacco plant, enabling it to create a pack of cigarettes with about as much nicotine as one Marlboro. It says generally that it uses “, including genetic engineering, gene-editing, and molecular breeding.”

Keeping 5% of the nicotine is enough to prevent smokers from seeking more to satisfy their craving, said , president of 22nd Century’s smoking division.

“There’s just enough in there that your brain thinks it’s getting it, but it’s not,” Miller said. “That was really one of the reasons we got to these levels of nicotine, is because you don’t have that additional smoking.”

Miller said the low-nicotine cigarettes can help some smokers cut back or quit, perhaps in conjunction with a nicotine patch or gum, when they’ve tried and failed with other stop-smoking programs.

Campaign for Tobacco-Free Kids President Matthew L. Myers supports the development of an industrywide low-nicotine standard, saying the concept would work only if consumers no longer had the alternative of a higher-nicotine cigarette.

“The concern with a product that’s still addictive, but delivers low levels of nicotine, in fact is that consumers will smoke more, because the evidence shows that somebody who’s addicted will smoke enough to satisfy their craving,” Myers said.

Both the FDA and cited studies that found lower levels of nicotine don’t prompt smokers to smoke more to reach the same nicotine levels. But those studies assumed smokers wouldn’t have a high-nicotine alternative, anti-smoking groups and researchers said.

Allowing low-nicotine cigarettes while conventional cigarettes remain available may be a public health detriment if they discourage smokers from quitting entirely or encourage others to start smoking because they think there’s a safe way to experiment with cigarettes, the Campaign for Tobacco-Free Kids and several health associations wrote in a letter to reverse its 22nd Century decision.

22nd Century’s cigarettes are still dangerous, and consumers must substantially cut back or quit smoking to get health advantages. But anti-smoking groups fear many smokers won’t understand that.

“If people are looking at this as a magic bullet and are still continuing their tobacco use, they are not doing anything to change their risk,” said Sward, of the lung association.

Anti-smoking groups particularly object to allowing 22nd Century to market menthol cigarettes even as the FDA is considering outlawing such cigarettes nationwide.

FDA spokesperson Abby Capobianco confirmed that 22nd Century has the only FDA-authorized low-nicotine cigarette but did not respond to requests for comment on the FDA’s plans for regulating nicotine in cigarettes.

California already flavoring, and Miller said the company won’t challenge that state’s ban and won’t sell its menthol cigarettes in California.

But Miller hopes the company will eventually win an exemption from any federal ban, in part, he said, because more than half of menthol smokers are likely to switch to conventional cigarettes.

“That’s not what the FDA wants to happen,” Miller said. “They need an offramp for these menthol smokers and ours is obviously the natural.”

The company is expanding into California, Florida, and Texas because of the nation-leading size of . It plans to also begin selling its very low-nicotine, or VLN, cigarettes this year in Arizona, New Mexico, and Utah, and it may move into 10 more states.

The company is prioritizing seven states that offer tax incentives for products the FDA has said reduce tobacco risk, believing its cigarettes will have a price advantage over others in Colorado, Connecticut, Kentucky, Michigan, North Carolina, New Mexico, and Utah. Miller said the company may lobby California lawmakers to add similar incentives as part of the state’s extensive efforts to discourage smoking, which still addicts .

Miller declined to disclose the company’s market share from the two test states but said sales were above expectations.

“If we can get this to the level of, like, a nonalcoholic beer — you know, 3% to 5% of the category — it’s a game changer,” Miller said. “We know that there’s a latent demand in the market for this product.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

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Instead, the FDA allowed all e-cigarettes already on the market to stay while their manufacturers applied for the OK to market them.

Seven years later, vaping has ballooned into an , and manufacturers are flooding the market with thousands of products — most sold illegally and without FDA permission — that can be far more addictive.

“The FDA has failed to protect public health,” said Eric Lindblom, a former senior adviser to the director of the FDA’s Center for Tobacco Products. “It’s a tragedy.”

Yet the FDA isn’t the only entity that has tolerated the selling of vapes to kids.

Multiple players in and out of Washington have declined to act, tied the agency’s hands, or neglected to provide the FDA with needed resources. Former Presidents Barack Obama and Donald Trump both have prevented the FDA from broadly banning candy-flavored vapes.

Meanwhile, today’s vapes have become “bigger, badder, and cheaper” than older models, said Robin Koval, CEO of the Truth Initiative, a tobacco control advocacy group. The enormous amount of nicotine in e-cigarettes — up — can addict kids in a matter of days, Koval said.

E-cigarettes in the U.S. now contain nicotine concentrations that are, on average, more than twice the level allowed in Canada and The U.S. sets no limits on the nicotine content of any tobacco product.

“We’ve never delivered this level of nicotine before,” said Matthew Myers, president of the Campaign for Tobacco-Free Kids, which opposes youth vaping. “We really implications.”

Elijah Stone was 19 when he tried his first e-cigarette at a party. He was a college freshman, grappling with depression and attention-deficit/hyperactivity disorder, and “looking for an escape.” Store clerks never asked for his ID.

Stone said he was “hooked instantly.”

“The moment I felt that buzz, how was I supposed to go back after I felt that?” asked Stone, now 23, of Los Angeles.

The e-cigarette industry maintains that higher nicotine concentrations can help adults who smoke heavily switch from combustible cigarettes to vaping products, which are relatively less harmful to them. The FDA has approved high-nicotine, tobacco-flavored e-cigarettes for that purpose, said April Meyers, CEO of the Smoke-Free Alternatives Trade Association.

“The goal is to get people away from combustible products,” said Nicholas Minas Alfaro, CEO of Puff Bar, one of the most popular brands with kids last year. Yet Alfaro acknowledged, “These products are addictive products; there’s no hiding that.”

Although e-cigarettes don’t produce tar, they do contain harmful chemicals, such as nicotine and formaldehyde. The U.S. Surgeon General has warned that vaping poses significant risks: including damage to , , and parts of the brain that control attention and learning, as well as an increased risk of addiction to other substances.

More than 2.5 million kids , including 14% of high school students, according to the Centers for Disease Control and Prevention.

Most U.S. teen vapers of waking up, according to a survey of e-cigarette users ages 16 to 19 presented at the Society for Research on Nicotine and Tobacco in March.

The potential for profits — and — has led to a gold rush. The number of unique vaping products, as measured by their bar codes, , rising from 453 in June 2021 to 2,023 in June 2022, according to a Truth Initiative review of U.S. retail sales data.

FDA officials say they’ve been overwhelmed by the volume of e-cigarette marketing applications — 26 million in all.

“There is no regulatory agency in the world that has had to deal with a volume like that,” said Brian King, who became director of the FDA’s Center for Tobacco Products in July 2022.

The agency has struggled to stop e-cigarette makers who continue selling vapes despite the FDA’s rejection of the products, as well as manufacturers who never bothered to apply for authorization, and counterfeiters hoping to earn as much money as possible before being shut down.

In 2018, public health groups , charging that the delay in reviewing applications put kids at risk. Although a court ordered the FDA to finish the job by September 2021, the FDA . An estimated 1.2 million people under the legal age of 21 began vaping over the next year, according to a study in the American Journal of Preventive Medicine.

Recently, the FDA announced it has of e-cigarette applications, noting that it had rejected millions and authorized 23. All authorized products have traditional tobacco flavors, and were deemed “appropriate for the protection of public health” because tobacco-flavored products aren’t popular with children but provide adult smokers with a less dangerous alternative, King said.

The agency has yet to make final decisions on the most popular products on the market. Those applications are longer and need more careful scientific review, said Mitch Zeller, former director of the FDA’s Center for Tobacco Products and a current advisory board member for Qnovia, which is developing smoking-cessation products.

The FDA said it would not complete reviewing applications by the end of June, as it but would need

Before the FDA can announce new tobacco policies, it needs approval from the president — who doesn’t always agree with the FDA’s priorities.

For example, Obama rejected FDA officials’ proposal to ban kid-friendly flavors in 2016.

And in 2020, Trump backpedaled on his own plan to pull most flavored vapes off the market. Instead of banning all fruit and minty flavors, the Trump administration such as Juul. The flavor ban didn’t affect vapes without cartridges, such as disposable e-cigarettes.

The result was predictable, Zeller said.

Teens from Juul to brands that weren’t affected by the ban, including disposable vapes such as , which were allowed to continue selling candy-flavored vapes.

After letter from the FDA last year, Puff Bar now sells only zero-nicotine vapes, Alfaro said.

When the FDA does attempt bold action, legal challenges often force it to halt or even reverse course.

The FDA from the market in June 2022, for example, but was immediately hit with a lawsuit. The U.S. Court of Appeals for the D.C. Circuit sided with Juul and issued a temporary stay on the FDA’s order. Within weeks, the FDA announced it would hold off on enforcing its order because of “scientific issues unique to the JUUL application that warrant additional review.”

E-cigarette makers Logic and R.J. Reynolds Vapor Co. both after the agency ordered them menthol vapes, a flavor popular with teens. In both cases, court-imposed stays halted the FDA’s orders pending review and the companies’ menthol products remain on the market.

Luis Pinto, a spokesperson for parent company Reynolds American, said, “We remain confident in the quality of all of Reynolds’ applications, and we believe that there is ample evidence for FDA to determine that the marketing of these products is appropriate for the protection of public health.”

Under the Biden administration, the FDA has begun to step up enforcement efforts. It more than $19,000 each, and has issued more than 1,500 warning letters to manufacturers. The FDA also issued warnings to 120,000 retailers for selling illegal products or selling to customers under 21, King said. Five of the companies that made vapes decorated with cartoon characters, such as Minions, or were shaped like toys, including Nintendo Game Boys or walkie-talkies.

In May, the FDA put Elfbar and other unauthorized vapes from China on its “red list,” which allows to without inspection at the border. On June 22, the FDA announced it has issued for selling unauthorized tobacco products, specifically Elfbar and Esco Bars products, noting that both brands are disposable e-cigarettes that come in flavors known to appeal to youth, including bubblegum and pink lemonade.

In October, the Justice Department for the first time against six e-cigarette manufacturers on behalf of the FDA, seeking “to stop the illegal manufacture and sale of unauthorized vaping products.”

Some lawmakers say the Justice Department should play a larger role in prosecuting companies selling kid-friendly e-cigarettes.

“Make no mistake: There are more than six e-cigarette manufacturers selling without authorization on the market,” Sen. Dick Durbin (D-Ill.) said in a . Children are “vaping with unauthorized products that are on store shelves only because FDA has seemingly granted these illegal e-cigarettes a free pass.”

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Until mid-March, these numbers commanded attention. But as the coronavirus death toll climbs and the economic costs of attempting to control its spread wreak havoc, the public health focus is now dramatically different.

In the background, though, these other issues — the opioid epidemic and vaping crisis — persist in heaping complications on an overwhelmed public health system.

It is creating a distinctly American problem, said Dr. Nora Volkow, who heads the National Institute on Drug Abuse.

Volkow spoke with Kaiser Health News about the emerging science around COVID-19’s relationship to vaping and to opioid use disorder, as well as how these underlying epidemics could increase people’s risks. Her remarks have been edited for length and clarity.

Q: We’ve already been experiencing two epidemics at once — vaping and the opioid crisis — and now we’re in the midst of a third. Does that change the nature of addressing the coronavirus in the United States?

It makes a different kind of situation than we see abroad. It forces us as a country to be urgently multitasking, to focus on the urgent needs of COVID while not ignoring the other epidemics devastating America. That’s certainly challenging.

Q: What is the evidence around the relationship between vaping and the coronavirus?

Because of the recency, there’s no data to show if there are differences in outcomes between people who vape and people who do not vape. There’s no reported scientific evidence. We will start seeing it.

We know from all the cases of acute lung injury that vaping, particularly certain combinations of chemicals that were related to vaping of THC, actually led to death. The cause of death was pulmonary dysfunction. We know from animal experiments that vaping itself — not even giving any drugs with it — can produce inflammatory changes in the lung.

We already know for COVID that, with comorbid conditions — particularly those that affect the lungs, the heart, the immune system — [patients] are more likely to have negative outcomes.

One can predict an association. In the meantime, because of the data that already exist, we should be very cautious. The prudent thing is to strongly advise individuals who are vaping to stop.

Q: Young people so far appear to have lower risks of COVID complications. Does vaping change that?

We know there have been fatalities among young people. One very important area of research is to try to understand the specific vulnerabilities among young people.

Why would you want to risk it when you already know vaping produces inflammatory changes in the lungs? We know in medicine, a tissue that has suffered harm is more vulnerable.

The big centers where you are observing the rise in COVID-19 cases, that’s where you are more likely to see the comorbidity of vaping.

It’s young people that are mostly vaping, but also older people, many of whom otherwise would be smoking tobacco. [Smoking] also raises the risk. Even though the samples have not been large enough, overall, smokers have done worse than nonsmokers when they have COVID.

Q: Let’s talk about opioid use disorder. What kind of comorbidities are we starting to see between opioid use disorder and COVID-19?

People who have opioid use disorder are also likely to be smokers. Smoking itself increases harm to your lungs.

We do know that opioids actually are immunosuppressants. This has been extensively studied. Nicotine also can disrupt immunity and actually impair the capacity of the cell to respond to viral infections.

One of the things opioids do is they depress your respiration. If it’s severe enough, they stop breathing. That’s what leads to death.

Whether you overdose or not, when you are taking opioids, the frequency of your breathing is down, and the oxygen in your blood tends to be lower.

The [COVID] infection targets the respiratory tissues in the lungs. It interferes with the capacity to transfer oxygen into the blood.

If you get COVID and you are taking opioids, the physiological consequences are going to be much worse. You’re not only going to have the effects of the virus itself, but you’ll have the depressive effects of opioids in the respiratory system [and] in the brain that lead to much less circulation in the lungs.

Q: What about other supports for people in recovery?

Community support systems like syringe exchange programs are closing. Methadone clinics are closing. If they’re not closing, they’re unable to process the same number of patients — because the staff is getting sick or the place where the methadone clinic was does not allow for so many people. Public transportation is not available for people to attend their methadone clinics.

We’re also hearing from our investigators they have observed a significant reduction in the capacity of the health care system to initiate people on medication for opioid use disorder — especially buprenorphine. Many of the buprenorphine initiations were done in health care facilities that are saturated with COVID.

Q: What’s happening to address those problems?

If in the past, if you were a physician or a nurse practitioner and you wanted to initiate someone on buprenorphine, the laws were that you needed to see that person physically. That’s changed. It’s now possible you can initiate someone on buprenorphine through telehealth. That’s incredibly valuable.

There’s extended reimbursement for telehealth, which expands access to treatment. There are also apps that have been created that provide individuals who have addiction [access] to mentors or coaches, as well as access to therapies and group therapies.

That is one of the aspects that has actually been accelerated by the COVID crisis. These may facilitate treatment into the future, even when COVID’s no longer there.

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Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.

Yet today, some of the in public health are unraveling.

Even as the world struggles to control a mysterious new viral illness known as COVID-19, U.S. health officials are refighting battles they thought they had won, such as , and protecting young people from . These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.

Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years — the longest sustained drop since the Spanish flu of 1918, which killed about and 50 million people worldwide, said Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.

Although life expectancy , it hasn’t yet regained the lost ground, according to the Centers for Disease Control and Prevention.

“These trends show we’re going backwards,” said Dr. Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.

While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.

“We’ve had an overwhelming investment in doctors and medicine,” said Dr. Sandro Galea, dean of the Boston University School of Public Health. “We need to invest in prevention — , , and

The country has split into , often , but with vastly different life expectancies. Americans in the are — hoping to live to 100 and beyond — while residents of the are dying from preventable causes decades earlier, which pulls down life expectancy overall.

— resistant to even the strongest antibiotics — threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, in spite of treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the U.S.

With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, said the world has entered a Half of all , for example, are resistant to at least one type of antibiotic, and the CDC warns that “little now stands between us and untreatable gonorrhea.”

That news comes as the CDC also reports of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.

The United States has seen a resurgence of , a , which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.

Those numbers illustrate the “failure of American public health,” said Dr. Cornelius “Neil” Clancy, a spokesperson for the Infectious Diseases Society of America. “It should be a global embarrassment.”

The proliferation of resistant microbes has been , by doctors who write as well as farmers who give the drugs to , said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

Although new medications are urgently needed, drug companies are because of the financial risk, said Clancy, noting that two developers of antibiotics recently The federal government needs to do more to make sure patients have access to effective treatments, he said. “The antibiotic market is on life support,” Clancy said. “That shows the real perversion in how the health care system is set up.”

A Slow Decline

A closer look at the data shows that American health was beginning to suffer 30 years ago. slowed as manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.

By the 1990s, life expectancy in the United States was falling behind that of other developed countries.

The , which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, “the gains we’re making at the tail end of life cannot make up for what’s happening in midlife.”

Progress against overall heart disease has stalled since 2010. Deaths from — which can be caused by high blood pressure and blocked arteries around the heart — are Deaths from high blood pressure, which can lead to kidney failure, also have

“It’s not that we don’t have good blood pressure drugs,” Khan said. “But those drugs don’t do any good if people don’t have access to them.”

Addicting A New Generation

While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking activists were optimistic enough to talk about the

Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students fell from to today, studies show used electronic cigarettes in the previous month.

say they’ve taken “vigorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren’t being marketed or sold to kids.” But Myers said FDA officials were slow to recognize the threat to children.

With more than using e-cigarettes, Myers said, “more kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn’t reversed rapidly and dynamically, it threatens to undermine 40 years of progress.”

Ignoring Science

Where children live has long determined their risk of infectious disease. Around the world, children in the often lack access to lifesaving vaccines.

Yet in the United States — where provides free vaccines — some of the lowest vaccination rates are in , where some parents disregard the medical evidence that vaccinating kids is safe.

Studies show that vaccination rates are drastically lower in some private schools and than in public schools.

It could be argued that vaccines have been a victim of their own success.

Before the development of a vaccine in the 1960s, measles infected an estimated a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.

By 2000, , and the United States declared that year that it had .

“Now, mothers say, ‘I don’t see any measles. Why do we have to keep vaccinating?’” Schaffner said. “When you don’t fear the disease, it becomes very hard to value the vaccine.”

Last year, a measles outbreak in New York communities with low vaccination rates spread to people — the most in 25 years — and nearly cost the country its measles elimination status. “Measles is still out there,” Schaffner said. “It is our obligation to understand how fragile our victory is.”

Health-Wealth Disparities

To be sure, some aspects of American health are getting better.

Cancer death rates have fallen 27% in the past 25 years, according to the The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the And HIV, which was once a death sentence, can now be controlled with a . With treatment, can live into old age.

“It’s important to highlight the enormous successes,” Redfield said. “We’re on the verge of in the U.S. in

Yet the health gap has grown wider in recent years. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a .

The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the study.

“We’re not going to erase that difference by telling people to eat right and exercise,” said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. “Personal choices are part of it. But the choices people make depend on the choices they’re given. For far too many people, their choices are extremely limited.”

The infant mortality rate of black babies is twice as high as that of white newborns, according to the . Babies born to well-educated, middle-class black mothers are more likely to die before their 1st birthday than babies born to poor white mothers with less than a high school education, according to a report from the .

In trying to improve American health, policymakers in recent years have focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the that erodes

“So many of the changes in life expectancy are related to Besser said. “ go hand in hand.”

Several policies have been shown to improve health.

, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.

And — which provide refunds to lower-income people — have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.

Improving a person’s environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America’s Health.

“If we think we can treat our way out of this, we will never solve the problem,” Auerbach said. “We need to look upstream at the .”

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Can’t see the audio player?Ìý.

Democratic state attorneys general are asking the Supreme Court to intervene this term in a case that could invalidate the entire Affordable Care Act. In December, a federal appeals court panel ruled that the “individual mandate” provision of the health law is unconstitutional now that Congress has reduced the penalty for not having insurance to zero. But it sent the case back to the lower-court judge to determine how much else of the law can remain in light of that finding.

Democrats want the high court to rule on the case now, which would be unusual but not unprecedented.

Meanwhile, Republicans on Capitol Hill are asking the Supreme Court to use a Louisiana abortion case already on this year’s docket to overturn the landmark abortion rights case, Roe v. Wade. The Louisiana law — requiring doctors who perform abortions to have admitting privileges at nearby hospitals — is similar to a Texas law struck down by the court in 2016. But the court has added anti-abortion justices since then.

This week’s panelists are Julie Rovner from Kaiser Health News, Joanne Kenen of Politico, Stephanie Armour of The Wall Street Journal and Paige Winfield Cunningham of The Washington Post

Among the takeaways from this week’s podcast:

• The Democratic push to get the Supreme Court to quickly review the latest ACA challenge could have political benefits for the party in the campaign season. Democrats are eager to be seen as protecting new health care benefits. And if President Donald Trump is elected next fall, the high court could well become more conservative as several liberal-leaning justices may leave the court in the next few years.
• Some advocates for a “Medicare for All” health care system are convinced that if the Supreme Court were to strike down the ACA, the resulting vacuum would make a government-run program more attractive to Americans.
• Amid increasing efforts by states to restrict abortions and a more conservative majority on the Supreme Court, abortion may become a more potent voting issue for Democrats. It has long motivated Republican voters, but Democrats have been less driven by that single issue.
• The much-publicized administration rules to cut back on flavored vaping products include a lesser-known provision allowing companies to go through a Food and Drug Administration process to prove their products have a net health benefit: helping adults quit smoking.
• States continue to seek Trump administration approval for work requirements for their Medicaid programs, but if Democrats win the presidency in 2020, those approvals are likely to be reversed. Meanwhile, most of the state plans are tied up in court.

Also this week, Rovner interviews NPR’s Richard Harris, who reported the latest KHN-NPR “Bill of the Month” installment about a very expensive laboratory bill for a New York woman who had a cold. If you have an outrageous medical bill you would like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Stat News’ “,” by Nicholas Florko

Joanne Kenen: The New Yorker’s “,” by Ariel Levy

Stephanie Armour: The New York Times’ “,” by Margot Sanger-Katz

Paige Winfield Cunningham: KHN’s “Reduce Health Costs By Nurturing The Sickest? A Much-Touted Idea Disappoints,” by Dan Gorenstein and Leslie Walker. You can hear the episode of Dan’s podcast, “Tradeoffs,” about this study .

To hear all our podcasts,Ìýclick here.

And subscribe to What the Health? onÌý,Ìý,Ìý,Ìý, orÌý.

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As vaping has grown more popular in recent years, the trend has been fueled by the habit’s pleasurable allure: Compared with smoking cigarettes or pot, vaping is discreet and less smelly. Vaping fluids come in hundreds of flavors. There’s no tar or other byproducts of burning. And vape pens are high-tech, customizable and sleek.

But none of that mattered to Paul Lubell when he decided to try vaping. He wasn’t thinking about pleasure; he was trying to avoid pain. The retired Navy veteran turned to vaping marijuana, hoping it would help him cope with his chronic, debilitating musculoskeletal pain.

Unfortunately, it wasn’t long before he became part of the national statistics tracking an outbreak of a vaping-related lung illness that has more than 50 Americans and sickened 2,400. Lubell ended up in the hospital, seriously ill from vaping an oily liquid containing extracts of THC, the psychoactive ingredient in marijuana.

Lubell, who lives in the Cleveland suburb of Beachwood, is older than most of those who have contracted what is now being called “e-cigarette or vaping associated lung injury,” or EVALI.

Three-quarters of patients with the condition have beenÌý; Lubell is 59.

But like patients in the majority of those cases, he used THC. And the latestÌýÌýsuggests that it’s some added ingredient in THC vapes — likely vitamin E acetate — that is causing the lung disease. The CDC is warning people to stop vaping altogether, given the risk of lung illness, which puts people who vape to manage pain in a tough position.

‘My Pain Would Be Gone’

Lubell suffers from pain in his back, neck and knees. He is not sure when his problems started, but he wonders if they are related to his days on a Navy helicopter rescue team.

“It was fun. I was indestructible and good at what I did. Everybody wanted me,” he recalled, while looking at photos of his much younger self posing on top of one of the helicopters.

Lubell sometimes jumped out of the helicopter and smacked into the water during training and rescue missions. That could have been the genesis of some of his back pain, he said. Lubell has had two back surgeries, and he also suffers from serious neck pain. Every day is a struggle, he said.

Looking for relief, he has tried many medications, including opioids such as hydrocodone, but that drug is no longer an option. Lubell is a patient atÌý, and in the wake of the national opioid addiction epidemic, the VA has revised its pain-treatment protocols.

“The VA is not a friend of opioids at all,” Lubell said. “Unless you’re coming out of the hospital for surgery or something like that, they do not give vets opioids.”

“It leaves someone who is in chronic pain in a very tough situation, having to decide how to deal with it,” he added.

Lubell started using an electronic cigarette device paired with prefilled THC cartridges. Medical marijuana is legal in Ohio, as it is inÌý, plus the District of Columbia.

“When I say it took away pain — it was almost instantaneous,” he said. “Within the span of 10 minutes, my pain would be gone. … It made me capable of doing my daily activities.”

Lubell described his old vaping cartridges as tiny sticks that screwed on top of the vaping pen. When he inhaled at one end of the pen, it pulled the THC extract and other liquids in the cartridge over a heating element. Vaping was different from when he had smoked marijuana, Lubell said.

“It doesn’t have a stench to it. You could do it out on the streets. It doesn’t have that — what’s the word I’m looking for? — stigma,” he said.

Hospitalized With Cough And Fever

Lubell purchased the THC cartridges from a friend at what he described as a below-market price. A few months later, in July, Lubell started running a very high fever and went to the Cleveland VA Medical Center.

“He had this cough that was persistent. He just looked very, very sick,” recalled Dr. Amy Hise, who was on the team of physicians that treated Lubell.

“He was put on very strong broad-spectrum antibiotics, and yet he continued to have fevers. He continued to feel unwell. He had very flu-like symptoms,” Hise said.

After a few days, Lubell seemed to improve and was released, according to Hise. But then, he grew ill again.

Hise said she was surprised when he came back to the emergency department in late August.

By then, however, she had seen a new alert from the CDC about the vaping illness. Lubell had also seen reports in the media about health problems related to vaping.

“He was forthright that he had been vaping, and indeed what had happened is when he was in the hospital before, he’d stopped vaping,” Hise said. “He stopped for a period of time until he started to feel better. And then he started it up again, and that’s when his lung disease came back.”

The doctors at the VA switched tactics, taking Lubell off antibiotics and starting him on steroids, based on information provided by the CDC. Lubell was soon released and on the road to recovery.

No More Vaping

Even though vaping eased his pain, those two bouts of respiratory sickness were too much. Lubell said he won’t vape again, and his doctor endorsedÌýthat decision.

“I think there’s just too much that’s not known about what’s in these products to safely use them,” Hise said.

But Lubell is not alone in having turned to marijuana for pain management.Ìý, a pain management specialist at University Hospitals, said many patients have told her they are trying marijuana to see if it will help.

“That is probably something that I get from patients every day,” Lawrence said. “And it’s not just people who are young, in their 20s. [There are] people in their 80s who are telling me they are looking to try anything to help with their pain.”

Even though some patients say marijuana helps their pain, there is not enough research to prove it’s broadly and reliably effective, Lawrence said.

“Personally, I don’t recommend it for my patients. But maybe after we have more studies, it can be something in the future” she said.

Lubell, who has an Ohio medical marijuana card, is still planning to use marijuana — but he won’t vape it. He turned over his equipment and leftover THC cartridges to health officials for analysis.

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