Vaping draws federal warnings, rebuke amid billowing health concerns

Hundreds of serious respiratory cases compounded by six deaths prompted a strong federal response into electronic cigarettes as health authorities go after the "safe alternative" to cigarettes. Now, health care providers may need to reanalyze their smoking education repertoire to account for late-breaking developments in vaping.

Earlier in September, the Centers for Disease Control and Prevention (CDC) announced a coordinated investigation with the Food and Drug Administration (FDA) and other public health agencies into the "multistate outbreak of severe pulmonary disease" associated with e-cigarette use. As of Sept. 6, the investigation had identified over 450 cases in 33 states, including six deaths.

Only days later, Trump administration officials announced it would explore a ban on the sale of flavored e-cigarettes amid the health concerns. The FDA acknowledged a plan would be forthcoming in a matter of weeks. But, in the meantime, investigators still search for a commonality among the respiratory cases, reportedly speculating that a culprit may lie in the vaping liquid itself.

Typically, e-cigarettes contain nicotine, flavoring and colorless chemicals, such as vegetable glycerin or propylene glycol, that are heated to create a vapor the user inhales. A theory posited by New York health officials suggests that one vaping compound, vitamin E acetate, could create an oily buildup on the lungs and trigger pneumonia. However, the federal investigation hasn't ruled out other explanations, as well, including vaping products containing tetrahydrocannabinol.

Until a determination is made, the CDC advises against using e-cigarette products. But even that wasn't the end of vaping-related headlines in a matter of days as the FDA took another, unrelated step toward reining back vaping companies.

On Sept. 9, the FDA issued a warning letter to the e-cigarette company, JUUL, for marketing its products as a safer alternative to smoking and ordered the company to stop marketing the unproven claims, especially toward youth. The FDA letter specifically identified statements a JUUL representative made at a high school presentation-discussed in a July 2019 Congressional hearing-including that:

• JUUL "was much safer than cigarettes" and that "FDA would approve it any day."
• JUUL was "totally safe."
• A student "...should mention JUUL to his [nicotine-addicted] friend ... because that's a safer alternative than smoking cigarettes, and it would be better for the kid to use."

"Regardless of where products like e-cigarettes fall on the continuum of tobacco product risk, the law is clear that, before marketing tobacco products for reduced risk, companies must demonstrate with scientific evidence that their specific product does in fact pose less risk or is less harmful," notes Acting FDA Commissioner Ned Sharpless, M.D., in a news release.

"We will continue to scrutinize tobacco product marketing and take action as appropriate to ensure that the public is not misled into believing a certain product has been proven less risky or less harmful. We remain committed to using all available tools to ensure that e-cigarettes and other tobacco products aren't being marketed or sold to kids."

Additionally, the FDA "put the industry on notice" that even more aggressive action is forthcoming should the rise in youth e-cigarette use continue, especially through use of flavored vapors. In fact, the 2018 National Youth Tobacco Survey showed a 78% increase in high schoolers vaping, between 2017 and 2018, as well as a 67.8% increase in high schoolers' use of flavored e-cigarettes. 

Although e-cigarettes don't contain many of the cancer-causing byproducts of cigarette smoke, there isn't much evidence of the long-term effects of vaping. E-cigarettes still contain addictive nicotine, a substance that raises blood pressure and heart rate, and a health danger for pregnant women; may still aggravate asthma conditions; and now, evidence suggests there could be ocular health considerations, too.

Vaping and the ocular surface

Published in September's Optometry and Vision Science, a small-scale study of 21 vapers and 21 healthy nonsmokers found moderate-to-severe symptomatic dry eye and poorer tear film quality among the former as opposed to the latter. Additionally, researchers noticed significant reductions of noninvasive tear breakup time, fluorescein breakup time and tear meniscus height among vapers while vaping at higher voltages.

This small-scale study is among the first to publish categorical results of vaping and ocular health, though a 2017 study found some flavor additives in e-cigarettes contained chemicals that exacerbate oxidative stress and an inflammatory response, both of which may affect the eyes. So, too, high-voltage e-cigarette use may produce formaldehyde, another possible carcinogen and known eye irritant.

Ocular surface concerns aside, Dan Bintz, O.D., AOA Health Promotions Committee member, says doctors of optometry and staff need to continue thinking beyond the eye when it comes to tobacco use. That includes reinforcing patient education of smoking's negative health consequences, as well as directing smokers to tobacco cessation resources-and e-cigarettes are not the answer, Dr. Bintz says.

"The e-cigarette phenomenon was originally designed to promote tobacco cessation; whether consumers or corporations took a turn, I am not sure, but it soon turned into the 'Wild West' with no moral compass," he says.

"The recent 'epidemic' of illnesses and deaths has finally caught everyone's attention. There is no reason for an adult to need a flavored nicotine delivery device-these were meant, from day one, to be marketed to children."

AOA supports smoking education, cessation efforts

Although cigarette use among Americans continue a decades-long downward trend, many health authorities worry e-cigarette use among today's youth could stagnate or reverse that overall trend in the future. As such, the FDA recently issued a proposed rule to require new warnings on cigarette packaging and tobacco advertisements that depict graphic, photo-realistic images of lesser-known health consequences of smoking. Among these proposed labels include blackened lungs, neck cancer, gangrenous toes, and a pair of eye conditions-AMD and cataracts-alongside blatant warning messages.

The FDA hopes such graphic warning labels will be highly discernible, considering daily smokers could see the warnings some 5,100 times per year and the public may spy images in ads or stores where cigarettes are sold. For its part, the AOA strongly supports the measure to warn against the ill-effects of smoking and especially the messaging that smoking can lead to blindness.

"Until now, most comprehensive health promotion activities surrounding smoking have included little information about vision and eye health complications that are linked to or exacerbated by cigarette smoking," says AOA Chief Public Health Officer Michael Duenas, O.D.

"It is wonderful to see vision and eye health conditions become linked to packaging public health campaigns, as eye disease images and new warnings will foster a team approach to smoking prevention and, ultimately, more fully achieve improved community health."

Want information about how to consult patients on smoking? Access these AOA and federal resources:

• "Smoking, Vaping and Your Eyes" fact sheet.
• Smoking cessation resources from smokefree.gov.
• Learn about e-cigarettes and the nation's youth.