Tobacco 21 Laws' Benefits Are An Illusion

Another recent study found that while self-reported teen smoking and vaping rates declined after Tobacco 21 laws, biomarker exposure showed mixed evidence at best, implying that fewer young smokers are identifying as smokers (and similar findings for vaping).  Thus, the supposed reductions in smoking and vaping in surveys and sales data are at least largely an artifact of underreporting and cross-border shopping rather than real reductions.  Oops!

Looks like it was all just another mirage, kinda like with the 21 drinking age.  What next, a study that finds that water is wet and the sun rises in the east?

Case Closed: Tobacco 21 Laws Don't Work

The latest study of Tobacco 21 laws shows they were a resounding....DUD in terms or reducing young adult smoking, vaping, or smokeless tobacco use rates in the USA.  Being published in a famously anti-tobacco journal, Tobacco Control, the authors of course wanted to put a positive spin on it though nonetheless, as shown below (emphasis ours):  

Results Although we did not find evidence that state T21 laws were associated with cigarette, smokeless tobacco or ENDS [i.e. vapes] use overall, the federal T21 law was associated with lower use of all three tobacco products by 0.39–0.92 percentage points. State flavour restrictions were associated with lower use of cigarettes by 0.68 (−1.27 to –0.09) and ENDS by 0.56 (−1.11 to –0.00) percentage points, but not with smokeless tobacco. A three-way interaction revealed that state and federal T21 laws together were associated with a lower prevalence of ENDS use among 18–20 years, but there were no differences in cigarette use from both policies combined versus either alone.

Conclusion State and federal T21 laws are broadly effective at reducing adult tobacco use, while state flavour restrictions specifically lower use of cigarettes and ENDS.

Got that? The state level laws were useless, period, but the federal Tobacco 21 law passed in December 2019 was somehow "broadly effective" because it appeared to trivially reduce tobacco/nicotine product use by not even a full percentage point.  Never mind that that latter was not enforced until well into 2020, enforcement still remained spotty for a while, and that its passage coincided with two major confounds:  1) the EVALI (vaping illness) outbreak that, while clearly due to adulterated black market THC vape products, was fearmongered by the mainstream media to include all vape products, and 2) the COVID-19 pandemic that, for better or worse, seemed to discourage smoking and encourage quitting, since many people feared that smoking made them more vulnerable to the virus.  But no, it HAD to be due to the Tobacco 21 law, because reasons.  Or something. 

Even flavor restrictions were more effective than Tobacco 21 laws!

So how many IQ points did YOU lose from the mental gymnastics of reading all for the above quoted article abstract beyond the stuff in bold?  The study was behind a paywall of course, so we couldn't delve further into it, granted.  But even a cursory reading of the abstract shows that the Tobacco 21 laws are a joke, and not a very funny one at that.  And worse, it may have even driven some young vapers (back) to smoking, which would clearly be a net public health loss.  But try convincing the zealots of that!

These unimpressive findings dovetail nicely with other studies as well.  As for whether raising the tobacco/nicotine age limit from 18 to 21 reduces the use of such products among people under 18, the evidence for that is very weak and mixed at best.

As for the few previous studies that did appear to find statistically and practically significant effects from the Tobacco 21 laws, those apparent results are most likely a result of short-term effects as well as an artifact of confounders like cigarette tax hikes.  

(Cigarette tax hikes, which mean higher prices, are in fact one of the most effective and cost-effective ways to reduce smoking at the population level, though they still have their limits of course.  And while they may be classist, at least they are not ageist, and they don't blatantly violate anyone's civil rights.)

Regardless, even if Tobacco 21 laws were ever proven to be effective, Twenty-One Debunked would still oppose them on principle, as we believe that in a free society worthy of the name, civil rights inherently supersedes "public health".  That is true in regards to tobacco, alcohol, cannabis, or anything else.  

(Mic drop)

UPDATE:  A few older studies have found modest but significant decreases in retail tobacco sales following the raising of the smoking age to 21 in early adopter states like California and Hawaii.  And another study found no change in overall ever or current smoking among California 18-20 year olds, but did find a modest decrease in daily smoking among that age group relative to 21-23 year olds (whose daily smoking actually increased three years later) in the same state.  This of course echoes Miron and Tetelbaum (2009) as well as Asch and Levy (1987 and 1990), Males (1986), and Dee and Evans (2001) in regards to the 21 drinking age.  That is, endogeneity, early-adopter effects, short-term effects, and seesaw/delay effects all appear to be at play here.  The supposed miracle turned out to be a mirage all along, in other words.  Thus, especially in light of the most recent study discussed in this article, there were really no benefits that cannot be alternatively achieved with higher cigarette taxes and/or better enforcement of the previous 18 age limit, and if anything the 21 age limit appears to be counterproductive in the long run.

UPDATE 2:  Even the CDC's very own 2022 study found mixed and ambiguous effects of Tobacco 21 laws, and such effects sometimes even appeared to differ by race as well (in favor of whites, with null or even perverse effects on young people of color).  Oops!

UPDATE 3:  Another recent study found that while self-reported teen smoking and vaping rates declined after Tobacco 21 laws, biomarker exposure showed mixed evidence at best, implying that fewer young smokers are identifying as smokers (and similar findings for vaping).  Thus, the supposed reductions in smoking and vaping in surveys and sales data are at least largely an artifact of underreporting and cross-border shopping rather than real reductions.  Oops!

Why Banning Tobacco Is A Dumb Idea

The stupid literally burns like, well, cigarettes.  It's apparently hard to keep a bad idea down.  While New Zealand's new government is backing off from the previous government's phased tobacco ban and plans to reverse it, as Malaysia already did as well, the UK government under Rishi Sunak now wants to implement such a phased ban for anyone born after 2008.  Even Bhutan lifted their tobacco ban in 2021, as it was such a massive failure due to the massive black market it created.  (Hey, somebody answer the Clue Phone, as it is ringing loud and clear now!)  So should they go through with it, the UK now stands alone in the modern (or even semi-modern) world, leaving them in the good company of...wait for it...the Taliban and ISIL in that regard.  Only difference being that the UK is simply taking the scenic route there instead of simply making a beeline for it.  Gee, how very enlightened and progressive of them.

Hey, don't go getting any ideas, California, or any other state for that matter!  Seriously. 

Smoking tobacco, especially in this day and age, is dumb, but banning it is even dumber.  People who fail to learn from history are doomed to repeat it.  Prohibition didn't work then, and it doesn't work now.

Boris Johnson Talks Some Sense For Once

Here's a good one from across the pond: 

Former Prime Minister of the UK, Boris Johnson, recently wrote an good article in the Daily Mail in which he actually talks sense for once.  Or at least, for the very first time since before that fateful day on March 22, 2020.  In his article, he strongly and very rightly criticizes the government's proposal to implement a New Zealand style generational smoking ban (that is, a lifetime smoking ban on anyone born after some arbitrary point in time).  He goes right to the heart of just how ridiculous the whole thing is.  And of course, we at Twenty-One Debunked also strongly oppose such an idea, not least because it is essentially the most extreme version of the very sort of fundamentally ageist policies that we despise.  

It basically raises the age limit (currently 18 in the UK) by a year every year, and of course we oppose 100% any attempt to set the age limit higher than 18.  While Twenty-One Debunked does not recommend that anyone of any age take up smoking or otherwise using tobacco, as it is a very foolish and dangerous habit with practically no objective benefits, we still believe that legal adults should have the right to do what they will with their own bodies and minds.

Of course, the proposed ban's defenders would likely claim that Johnson is being hyperbolic in his criticism.  Truly, no one is calling for the newly disenfranchised smokers themselves to be arrested or otherwise punished for smoking, right?  It's only the sellers of tobacco to people born after that arbitrary date who will actually be on the hook, right?  Well, as history has infamously shown with less extreme age limits for other substances and/or in other places, there is absolutely no guarantee of that, especially when the measure isn't nearly as quick or effective as initially hoped for, and the zealots inevitably begin to get impatient.  And even if penalties are limited to sellers, it's still utterly ridiculous at best, and an unjust infringement of civil rights at worst.

Perhaps old Alexander Boris de Pfeffel Johnson is at least somewhat redeemable after all?

The Stupid Literally Burns Like Cigarettes

In Australia, there is quite a furor right now among the chattering classes in regards to a sharp increase in teen tobacco smoking from 2018 to 2023 after over two straight decades of decline.  And one of the things people are blaming is.....wait for it....vaping.  Because reasons.  Or something.  But there is one very glaring problem with this theory.  In Australia, vape products are technically legal, but ONLY if they do NOT contain any nicotine at all, thus kind of defeating the purpose.  That's right, nicotine vape products have never been approved for legal sales in Australia (and probably never will be any time soon), meaning anyone who wants to use them must either smuggle them in from abroad or buy them on the black market.  And interestingly enough, vaping itself also appears to be on the rise as well down under.  Thus, it truly takes a special kind of stupid to not only perversely create a situation where vaping and smoking both increase at the same time, but to then blame the increase in smoking on vaping.

Even more notable is the fact that in Australia, cigarettes have some of the highest taxes (and thus prices) in the world, plus so many other world-leading "best practices" tobacco control polices as well.  This additionally shows that while vice taxes and some other policies may work well to a point, all of these policies inherently have their limits in practice. 

Our working theory:  it is actually the banning of nicotine vaping, combined with the harmful effects of one of the strictest lockdown and Zero Covid regimes in the world, that ultimately snatched defeat from the jaws of victory in the long fight against tobacco smoking, particularly for youth.  And we must stress that while nicotine in any form is far from benign and definitely NOT for kids, banning or unduly restricting vaping (which is still significantly safer than the known deadly habit of smoking that it often displaces) is therefore a net public health loser of a policy.  And a policy like Australia's that perversely increases "dual use" of both is even that much worse still.

One could even argue that their truly massive cigarette black market created by their insanely high taxes, especially combined with their vaping black market from their nicotine ban, actually increased underage (under 18) use of both products since black market sellers typically don't ask buyers for ID.

Note also how the increase did not begin until 2020 (implicating the lockdowns as a contributing cause), and occurred for 14-17 year olds but interestingly NOT 18-24 year olds (putting the lie to the idea that their age limit of 18, as opposed to 21, was in any way related).  Also note that in England, where the age limit is still 18 and vaping is literally promoted by public health authorities, teen smoking continued its long decline through at least 2021.  New Zealand, where the age limit was still 18 (until very, very recently), smoking rates among 15-24 year olds nosedived as soon as nicotine vaping was officially legalized in 2020, despite an even stricter lockdown there.  Thus it seems to be the combination of 1) black markets, 2) vaping bans, and 3) lockdowns that is the cause of the jump in teen smoking in Australia.

But good luck trying to convince the nanny-state zealots to use even a little bit of common sense!

QED

How To Make Tobacco Less Appealing And Addictive Without Banning It Or Reducing Nicotine Below Natural Levels

Here is a "Cliffs Notes" style list on how to make cigarettes and other smokeable tobacco products less addictive and appealing WITHOUT banning it outright, raising the age limit any higher than 18, or even reducing nicotine below natural levels:

• First and foremost, BAN ADDITIVES!  No non-tobacco ingredients should be added, period.
• Adding extra nicotine deliberately should also be banned as well.
• Require the smoke pH to be 8 or higher to discourage deep inhalation of smoke, as it naturally was prior to the 20th century. 
• Phase out the pH-lowering and environmentally unsustainable practice of flue-curing tobacco. 
• Phase out cigarette "filters", which don't really filter, and merely provide a false sense of security to smokers, and inherently creates a major toxic waste littering problem to boot.

If they still want to reduce maximum nicotine levels to a non-addictive level in ready-made commercial cigarettes and little cigars, go right ahead.  But it would be best to do the other things on the list first.

Also, banning the use of radioactive (!) phosphate fertilizers to grow tobacco is really a textbook no-brainer in terms of tobacco harm reduction. 

Additionally, requiring all tobacco products to be sold only in dedicated tobacco stores, or other places where you have to be 18 or older to enter, would really not be a bad idea either.  It would certainly make it less ubiquitous, convenient, and tempting without the constant reminder in grocery stores, convenience stores, gas stations, pharmacies, etc.

So what are we waiting for?

A Better Way To Phase Out Tobacco

California is now seeking to emulate New Zealand, Norway, Singapore, and the Philippines in phasing out tobacco products with a permanent generational ban on the sale of such to anyone born on after January 1, 2007.  Twenty-One Debunked has generally opposed such an idea on principle, as we had discussed previously.   Not only is it inherently ageist, and further promotes black markets, but it will drag it out and take decades to have the desired endgame effect.

Here's a better idea, that the FDA is already currently considering:  Reduce the maximum allowable nicotine levels in commercial cigarettes, and perhaps other combustible tobacco products, to a non-addictive or sub-addictive level.  This idea, or at least some flavor of it, has long been endorsed by many stakeholders and pundits the world over, from the American Medical Association to Robert N. Proctor to Malcolm Gladwell.  And Twenty-One Debunked has endorsed it since 2013, ideally keeping the legal age limit at 18 (which Congress and Trump unfortunately raised to 21 in late 2019, much to our chagrin).

By that, it means reducing nicotine levels by 95% or so from current levels, down to no more than 0.5 mg/g (0.05%) of tobacco.  Crucially, this would apply to nicotine content, not "delivery," as the latter can be gamed and manipulated too easily.

If done smoothly and gradually enough, and leaving noncombustible tobacco and nicotine products untouched, this will dramatically reduce smoking rates for all ages, and thus save thousands if not millions of lives without creating any more of a black market than already exists from high cigarette taxes alone.  Pairing it with a tax hike (within reason) would also increase its effectiveness as well.

Even if the new nicotine limits applied only to the sale of pre-rolled cigarettes and quasi-cigarettes like little cigars, and nothing else, it would likely still have the desired effect.  That is because those are the products that really drive the deadly tobacco epidemic.

It could be done in either one step with some lead time, or a few steps over a period of months to a year or two, for all cigarette manufacturing and importation going forward, plus an additional year to clear out excess inventory.  Doing it in a few steps would probably be better overall we think.  Either way would probably be fine though. 

Banning the use of additives, which are largely all about increasing the addictiveness of the products, would also make sense as well.  Michigan already has an excellent law on the books, that bans any "deleterious" ingredient or anything "foreign to tobacco" being added to cigarettes.  It needs enforcing.

Redesigning the cigarette to have a more alkaline smoke pH of 8 or higher, as it typically was prior to the 20th century, would make it less appealing and harder to inhale at least for new smokers.  Most cigars and pipe tobacco are already like that currently. 

And for the love of all that is good, ban the use of radioactive phosphate fertilizers yesterday!

Another good idea would be to only allow tobacco products to be sold in designated or dedicated tobacco-related stores (i.e. smoke and vape shops) and/or places that one needs to be 18+ to enter.

As for nicotine vapes, capping the maximum nicotine content at current European or Israeli levels (lower than USA levels but still generous) would reduce overall nicotine addiction rates without driving vapers back to smoking cigarettes.

Do these things and the desired endgame can be achieved in a matter of months to years, not decades.  But that would make too much sense, right?

FUN FACT:  Hemp-based, tobacco-free "blunt wraps" are now commercially available, so even the classic use of hollowed-out cheap tobacco cigars for rolling cannabis blunts is now thoroughly obsolete as well. 

UPDATE:  Apparently New Zealand will, starting in 2025, mandate that only very low nicotine cigarettes (VLNC) be sold, similar to what we advocate above.  Also, in 2024 they will sharply reduce the number of tobacco retail outlets by 90-95%, and ban the sale of cigarettes at kiosks, gas stations, or supermarkets.  This will be in addition to their generational ban for anyone born after January 1, 2009.  Thus, the generational ban is completely redundant and unnecessary, given the other two components.  And also the price of a pack of smokes there, $36 NZD, is the equivalent of over $20 USD (that is, more than a dollar per cigarette!) thanks to their already high taxes, making it a very expensive habit as it is.

And vape products would remain unaffected. 

Twenty-One Debunked's preferred plan, in a nutshell, is basically the New Zealand plan MINUS the generational ban and keeping the age limit at 18, plus a few other things above listed above.

UPDATE 2:  Bhutan, the only country in the 21st century that had completely banned tobacco across the board, has failed so miserably in doing so (thanks to the black market and international smuggling, and despite very stiff penalties too) that they ended up reversing their ban in 2021, largely out of fear that rampant cross-border smuggling would.... increase the spread of Covid.  Seriously, you cannot make this stuff up!  This should really be a cautionary tale.

Do Tobacco 21 Laws Really Work?

A recent study claims that Tobacco 21 laws work to reduce teen tobacco use.  But upon closer examination, there is less here than meets the eye.  While this new nationwide study controlled for a host of other variables and spanned from 2012-2019, it still leaves the reader with more questions than answers.  

For example, the supposed effect in survey data in grades 8, 10, and 12 was statistically significant for combustible cigarettes, particularly for grade 12, but NOT for vape products at any grade level, while for the Nielsen sales data the apparent effect was much larger for vape products than combustible cigarettes.  How exactly can this glaring contradiction be explained away?  Also, no significant effect was observed on heavy smoking, which intuitively should have had the largest effect size of all due to heavy smokers facing the greatest "hassle costs" when cigarettes become even somewhat more difficult to obtain.  And even for cigarette smoking in general, the absolute difference-in-differences was a few percentage points at most, for a substance whose popularity and prevalence was already declining among all ages long before the age limit was hiked to 21 (in contrast to vaping, which increased dramatically among young people during this period).

Furthermore, the study did not look beyond the first two years post-enactment of such laws, so any observed effects may very well be merely short-term effects (cf. Miron and Tetelbaum 2009 for the 21 drinking age and alcohol-related traffic fatalities).

Interestingly, the study authors do concede that at least some of the observed effect on people under 18 is a result of increased ID checking and increased perception of risk of of tobacco products.  Of course, we know that it is not really necessary to raise the age limit higher than 18 to achieve such effects.

Overall, this nationwide Tobacco 21 study (the second of its kind) was rather less impressive that an earlier nationwide study by different authors, for reasons that are not entirely clear.  But it is very likely a repeat of what we like to call "The Incredible Shrinking Effect Size", a phenomenon that we have seen before with studies of the 21 drinking age over time.  Which means that it was most likely a statistical mirage all along, at least in the long run.

Regardless of what sort of effects, or lack thereof, that Tobacco 21 laws supposedly had, we at Twenty-One Debunked nonetheless oppose such laws on principle 100%, just like we oppose the 21 drinking age and toking age as well.  Let America be America Again!

UPDATE:  A recent pro-21 article made a Freudian slip about what happened since Texas raised their smoking age to 21 in 2019:

"Since then, the use of tobacco by teens decreased from 21.8% in 2019 to 19.1% in 2021, according to the CDC and the American Lung Association."

That is NOT a particularly large difference in teen tobacco use (which includes both smoking and vaping), especially since teen vaping had already peaked by 2019 and teen smoking had already been plummeting for decades.  Technically, the latter data were from the 2020 Texas School Survey, not 2021, and the 2019 data were from the CDC YRBS, as each survey is done only every other year.  But either way, the point still stands.  In fact, when compared to the 2018 TSS data, the 2020 TSS data are almost identical.

2023 UPDATE:  The study in question has been recently revised, but not in a way that materially alters any of the above conclusions or criticisms.  In fact, reading between the lines, not only does the results look even less consistent and statistically significant than before, but now the effect size on survey results seems to be much larger for vaping than for smoking at all grade levels, implying that some vapers have likely switched to smoking.  That makes the Tobacco 21 policy a net public health loser.

2024 UPDATE:  A 2021 study of California, one of the first two states to implement a statewide Tobacco 21 law in 2016, showed weak and unimpressive numbers in a difference-in-differences analysis.  Womp womp.

Latest California Smoking Age Study More Smoke Than Fire

Last month, a new study looking at the results of California's smoking age hike from 18 to 21 in 2016 turns out to be less than meets the eye.  The study, looking at BRFSS survey data for 18-20 year olds pre versus post implementation, found that, compared to 21-23 year olds in California and to 18-20 year olds in the eight comparison states, 18-20 year olds did not see any significant change in the rate of decline of current or ever smoking, but did see significantly faster declines in the rates of daily smoking in the three years after the age limit was hiked to 21 versus before implementation.  Interestingly, vaping was not examined at all due to apparent data gaps at the time, so this study says absolutely nothing about vaping.

While the part about daily smoking sounds impressive on the surface, one should keep in mind that cigarette taxes were hiked by $2.00/pack in 2016 (effective April 2017), and generally the younger a person is, the more price-sensitive they are since they tend to have less disposable income, and furthermore the earlier they are in the course of their tobacco habits.  So it would stand to reason that the tax hike alone, which makes regular and especially daily smoking that much more of an expensive burden on the smoker, would have had a larger impact on 18-20 year olds than 21-23 year olds in California.  That would also explain why current or ever smoking (which were essentially not affected at all) would be much less affected than daily smoking as well.  

Of note, Pennsylvania had also raised their cigarette tax in 2016 yet still kept their age limit at 18 (until July 2020, that is), yet interestingly that state was NOT one of the eight comparison states.  The results of this study would thus likely have been very different if Pennsylvania was one of the comparison states.

Alternatively, some of the progression to daily smoking may simply have been delayed by a few years by the age limit hike, yielding no real long-run benefits, kinda like some studies have strongly suggested about drunk driving deaths when the drinking age was raised to 21.  Indeed, by 2019 the daily smoking rate among 21-23 year olds was actually a bit higher than it was in 2016.

And as we have previously noted, in NYC and elsewhere, raising the smoking age to 21 does not seem to actually reduce high school smoking rates compared with keeping it 18, so the "trickle-down" theory that is often used as a specious justification for Tobacco 21 laws is very unlikely to be the case in California (or anywhere else) either.

Thus, this study is more smoke than fire.  And regardless, we at Twenty-One Debunked would still oppose the 21 smoking age on principle regardless of its effects.  Young adults who are old enough to go to war, be tried as adults, etc. should NOT have the state dictating what otherwise legal substances they choose to put into their own bodies at all, period.  Seriously.

And that is a hill we will die on.

Et Tu, DeSantis?

Florida's controversial Governor Ron DeSantis (R) has been a bit of a mixed bag overall.  The True Spirit of America Party (TSAP) is, to put it mildly, not exactly a fan of Republicans in general and Trump supporters in particular, but has nonetheless generally agreed with his light-touch, focused protection handling of the COVID-19 pandemic, which has actually yielded a lower cumulative per capita death rate than the national average (and much lower than several lockdown states) despite Florida's significantly older and fatter population.  And in terms of excess all-cause mortality, wide-open Florida even did better than the overall strictest state of all, California.  There are some bad things about DeSantis of course, such as his latest Georgia-style voter suppression efforts and his heavy-handed and poorly-written anti-rioting law that arguably throws out the proverbial baby with the bathwater, but generally he is not too terrible by current low-bar Republican standards.

And of course, Twenty-One Debunked in particular has supported the fact that he was one of the most prominent holdouts in keeping the legal smoking age at 18 despite the trend towards raising it to 21 at the local, state, and eventually federal levels.  After all, he has previously opposed and vetoed every single attempt to raise Florida's smoking age any higher than 18.  Well, until now, that is.  Like most other governors, as of today, DeSantis has officially SOLD OUT and signed into law a bill that raises Florida's smoking and vaping age to 21, effective October 1, 2021.  True, this new law does have an exemption for military service members aged 18-20, making it a shade less bad than some other states, but we still oppose this law on principle like we oppose all inherently ageist Tobacco 21 laws, period.

One could argue that any state law that sets the age limit below 21 is effectively void since the federal smoking age has been 21 since December 2019, but that is beside the point.  A state that chooses to remain 18 in spite of the federal Tobacco 21 law is a principled state with integrity, and is at the very least NOT helping the federal government enforce such an ageist abomination.  Today, Florida lost that status.

DeSantis is now the 34th governor to raise the age limit for tobacco and vaping to 21, bringing it to now more than two out of three states who set it at 21.  With "allies" like him (and Trump, who raised the federal age limit to 21), who really needs enemies?

What About Tobacco, Again?

The Biden administration is currently considering two new sweeping FDA rules affecting combustible tobacco cigarettes:  1) banning menthol cigarettes and flavored cigars, and 2) reducing nicotine levels, presumably to a non-addictive level.  Where we stand on these two potential changes is as follows:

The first one, Twenty-One Debunked is on the fence about that, as we can see both sides of that issue, noting that Canada has already banned menthols and the EU has phased them out, while also noting the inconvenient truth of racism and how it intersects with this issue as well.   The flavored cigars we generally lean against banning, while for menthol cigarettes we believe that if they must do it for whatever reason, they should phase them out more gradually and allow existing stocks to be sold well after the designated "quit date" for selling newly manufactured menthols.  Also, possession and consumption of menthols should NOT be banned or punished, and police should NOT go out of their way to target the sale of menthols or "loosies" in underprivileged neighborhoods with people of color.

(For what it's worth, quit rates in Canada have improved significantly since their menthol ban, particularly among formerly menthol-preferring smokers.  That lends credence to the idea that menthol enhances the overall addictiveness of tobacco by making the high nicotine levels less harsh on the throat, which also makes it easier for young experimenters to pick up the habit in the first place.)

The second one, reducing nicotine levels, Twenty-One Debunked has cautiously supported since 2014, and we still do, provided that all of the following are true:

• The phasedown of nicotine to a non-addictive level is done gradually and stepwise over a period of at least a year, in at least three stages.
• The sale of existing domestic stocks of cigarettes above the nicotine cap can continue at least six months after the "quit date" for manufacturing and importing cigarettes above that cap (at each step of the phasedown).  
• The possession/consumption of cigarettes with nicotine levels above the cap is NOT banned or punished.
• The only other tobacco products subject to the same cap shall be little cigars (below a certain size), perhaps all cigars with a smoke pH below 8, and possibly loose roll-your-own cigarette tobacco and/or pipe tobacco with a pH below 8.  Nothing else, period.  We would be fine with, and would actually prefer, if only pre-rolled commercial cigarettes and little cigars (the size of cigarettes) were subject to the nicotine cap.  
• The addition of any harmful or addictive additives to all newly manufactured tobacco products is banned effective immediately as well.  All additives must meet the same standards as for additives to food.  Radioactive fertilizers for growing tobacco must also be banned as well.

While the effectiveness of the flavor ban is a bit questionable at best, the nicotine cap and phasedown would likely greatly reduce the prevalence of tobacco smoking and associated disease and death, simply by making this conveniently deadly product by design far less addictive.  More people would quit fairly quickly, and fewer people would take up the habit in the first place.  And people who miss the old high-nicotine smokes of yore would still be free to use alternative tobacco and nicotine products.

And doing it gradually enough will make it so there is no more of a black market for higher-nicotine cigarettes than there is for incandescent light bulbs.

As for vaping, Twenty-One Debunked does not support such a massive reduction in nicotine levels to that proposed for combustible cigarettes, but rather we support reducing the nicotine content in vape products to the maximum levels permitted in the EU, UK, and Israel.  That would nix the super-addictive ones that notoriously get young people hooked within seven days (JUUL, we're looking at you!) while still allowing plenty of nicotine for adult vapers who are trying to quit smoking.  (Twenty-One Debunked does NOT recommend anyone take up vaping, except as a last-ditch effort for truly hardened and refractory adult smokers who cannot quit any other way.)

Of course, we also think the smoking age should be lowered back to 18, just like we feel about the drinking age and toking age.  We are not called Twenty-One Debunked for nothing, after all.  Raising the age limit to 21 was at best useless, and is an ageist abomination.  In the meantime, though, the above is our nuanced and well-thought-out stance on the latest tobacco-related measures being proposed. 

FINAL THOUGHT:  By the way, the fact that they use the "think of the children!" argument to justify the banning of menthols and flavored cigars, is really just a tacit admission that raising the smoking age to 21 was essentially useless in keeping cigarettes and cigars from "trickling down" to people under 18.

How To Solve The Vaping Crisis In Five Easy Steps

First of all, the "vaping crisis" is actually two different problems that just happen to share the same delivery system.  The first is the explosion of nicotine vaping (particularly the JUUL brand, with very high nicotine levels) among teens from late 2017 onwards.  The second is the "mystery" vaping lung illness, now known as EVALI, that has finally been linked to the cause that we suspected for months now:  Mostly black-market and gray-market THC (and probably CBD) vape cartridges containing the additive Vitamin E Acetate, which is apparently VERY bad for the lungs.  Instead of conflating the two, we must realize that they are two different issues with different solutions, while also noting that pushing them into the black market will only pour gasoline on the fire.

Thus, Twenty-One Debunked recommends the following:

1. Legalize cannabis, vaping and otherwise, for everyone 18 and older, period. 
2. For cannabis vape products, ban Vitamin E Acetate and all other additives that are not on a narrow list of approved additives.  Implement strict quality control to test for questionable substances and issue product recalls as needed.  (Also require quality control of nicotine vape products while we're at it.)
3. Cap the nicotine content of nicotine vape products at similar levels as found in the UK, Europe, and Israel, and also subject such products to the same advertising restrictions as combustible cigarettes.
4. Tax nicotine vape products, but keep the tax lower than the tax on combustible cigarettes (or alternatively, raise the cigarette tax even higher).
5. Strictly enforce existing purchase age limits on vendors via compliance checks, but avoid knee-jerk reactionary policy measures such as broad flavor bans or raising the smoking/vaping age to 21, which will drive vapers to the black market.

Do these things and tone down the moral panic, and both of these problems will soon wither on the vine.  But that would make too much sense, of course.

The Federal Smoking And Vaping Age Is Now 21 (Part Deux)

As we had noted a little over a week ago, Congress raised the federal age limit for the sale of tobacco and vape products from 18 to 21 as part of a must-pass budget bill to avoid yet another government shutdown, and on December 20, 2019, Trump signed it into law, and even had the GALL to brag-tweet about it.  And while Republican Senate Majority Leader Mitch "Awkward Turtle" McConnell, a big supporter of the age limit hike, was no doubt very pleased with himself for his "victory", we need to remember that both parties overwhelmingly supported it.  Tyranny is apparently as bipartisan as it is whimisical--and very cowardly as well.  And of course, Big Tobacco and Big Vape overwhelmingly supported it like the cowardly quislings that they are.

If that wasn't bad enough, it looks like the FDA isn't wasting any time in implementing the raising of the tobacco and vape product sale age to 21.  As of December 27, 2019, they officially noted on their website that it is now illegal to sell tobacco or vape products to anyone under 21.  They could have waited up to 180 days to formulate new regulations plus an additional 90 days before enforcing them, according to the new law, but apparently even that very small mercy is somehow beneath them.  And of course there is no grandfather clause either in this disgusting new law, nor will there be in the FDA regulations.  In other words, 18-20 year old young adults in a whopping 31 non-21 states (and several territories) who were legal to buy cigarettes and vapes just a week ago are suddenly banned from buying them now.  Talk about adding insult to injury!

And of course the new federal 21 law also applies just as much to our men and women in uniform, despite a few Tobacco 21 states having the small mercy to carve out an exception for them.  The new federal law has NO such exceptions, and is really a slap in the face of so many of our troops.  You know, kinda like the 21 drinking age has been for over three decades now.

The only silver lining to this ageist abomination is that it may very well anger enough Americans to challenge it in court, and if successful, we may get the two-for-one special of getting that other ageist abomination, the 21 drinking age, struck down as well.  And possibly even for cannabis too, though federally there is no such age limit (yet).  Otherwise, there is really no upside to this new law.  All it will do is effectively create an even more massive black market and greater disrespect for the rule of law.

In fact, it may very well drive many teen and young adult nicotine vapers back to smoking, since even with strict enforcement, regular cigarettes will be at least somewhat easier to get than vape products due to the difference in the size of the markets, general accessibility, and the design of the products.  Talk about a lose-lose proposition for public health!

As a wise man once said, "America will never be destroyed from the outside.  Rather, if we lose our freedoms, it is because we have destroyed ourselves from within."  That wise man, Abraham Lincoln, did not use those exact words it turns out, but his words came very close nonetheless.  And that (mis)quote turned out to be very prescient indeed, as America really seems to be rotting and rusting from within.

The song "21 Guns" by Green Day comes to mind, as does the song immediately following it on the same album, "American Eulogy".  And of course there's also Five Finger Death Punch, with "Stranger than Fiction":

"It's stranger than fiction, how [we've] decayed..."

The Federal Smoking And Vaping Age Has Been Raised To 21

Well, it's now official.  As part of a must-pass budget bill to avoid yet another government shutdown, Congress attached several provisions unrelated to spending, most notably a rider that hikes the federal age limit for the sale of tobacco and vape products from 18 to 21 nationwide.  And on December 20, 2019, Trump signed it into law, and even had the GALL to brag-tweet about it.  And while Republican Senate Majority Leader Mitch "Awkward Turtle" McConnell, a big supporter of the age limit hike, was no doubt very pleased with himself for his "victory", we need to remember that both duopoly parties overwhelmingly supported it.  Tyranny is apparently as bipartisan as it is whimisical--and very cowardly as well.

For practical purposes, the new age limit actually takes effect after 180 days plus an additional 90 days, meaning an effective delay of nine months from the date of signing.  Thus, by September 2020, Tobacco 21 will have been fully phased in nationwide.

The text of the new federal Tobacco 21 law does two things:  1) amends the Family Smoking Prevention and Tobacco Control Act of 2019 by changing "18" to "21", and 2) while it technically no longer forces states to change their own laws (unlike the original version), nonetheless amends what was once called the Synar Amendment by requiring states to enforce (against vendors) the new federal age limit of 21 for the sale of tobacco and vape products, in order to quailfy for certain substance abuse prevention grant monies.

Though weaker than its original version, it is that second provision that may prove to be the Achilles heel of this law if it were to be challenged in court, on both Tenth Amendment as well as Fourteenth Amendment.  And if such a challenge ever proves successful, it will no doubt also overturn South Dakota v. Dole, and the National Minimum Drinking Age Act along with it.  But until then, it is long past time to be very, very angry at what passes for "leadership" in America's long, dark night of the soul.

Winter is coming, in more ways than one.

UPDATE:  Looks like the FDA isn't wasting any time in raising the tobacco and vape product sale age to 21.  As of December 27, 2019, they officially noted on their website that it is now illegal to sell tobacco or vape products to anyone under 21.  FEH.

Finally, Some "Reefer Sanity" In The Vaping Debate

It seems that at least some pundits, politicians, and public health officials are just starting to catch up with reality.  There is rapidly mounting evidence now that the primary culprit in the mystery vaping illness (that has killed over 40 people and sickened at least 2000 in the USA as of November 15, 2019) is the thickener additive Vitamin E Acetate in mostly black-market or counterfeit THC cartridges. This "thick and greasy" oil is harmless when used topically or ingested orally, but when inhaled it is apparently VERY bad for your lungs, much like any other "thick and greasy" oil would logically be.  And finally, several cannabis legalization and even medicalization states are belatedly banning or trying to ban its use in both legal and illegal THC cartridges, since until now almost no state banned or restricted this additive.

Better late than never, but honestly, what the hell took them so long?

THIS is what more states need to be doing.  Legalize cannabis, keep vaping legal in general, but regulate better and root out any bad actors in the legitimate market, while cracking down on any remaining illicit market that continues to hawk questionable wares.  In contrast, broad vaping or flavor bans, as well as cannabis prohibition and/or age limits set higher than 18, will only drive more customers to the black market, essentially pouring gasoline on the fire.  And those who foolishly opted for the later strategy while dithering over the real cause now have the blood of over 2000 Americans on their hands.

Of course, Vitamin E Acetate may not be the only culprit.  Other additives may also be to blame, as can perhaps the toxic cadmium fumes from cheaply-made and janky vaping devices and cartridges often made overseas (which can also be true for counterfeit nicotine vapes too, by the way).  And possibly pesticide contamination as well.  But again, in any case regulation would still work far better than prohibition to really get to the root of the problem.

As for the youth vaping epidemic driven by nicotine vapes, which is often disingenuously conflated with the mystery vaping illness, the best way to quash that is to raise the tax on nicotine-containing vape products, cap and phase-down the nicotine content of vape products down to European and Israeli levels, strictly enforce the existing age limit of 18 on vendors rather than raise it to 21, restrict vape advertising to be similar to the way it currently is for combustible tobacco products, and stop hyping this ridiculous moral panic so damn much for once.

So what are we waiting for? 

The Needham, Massachusetts "Miracle", Debunked

Remember when Needham, Massachusetts made history in 2005 by being the first place in the USA to raise the age limit for tobacco to 21 in modern times?  And how the propoents of Tobacco 21 laws used them as an example of how successful such laws supposedly are at reducing teen smoking?  Well, a new article came out that thoroughly debunks that claim.  Scratch that, it debones, slices, dices, and juliennes it, and lays waste to its remains for good.

From 2006 to 2010 (the original study curiously did not include data before 2006), Needham did indeed see a faster drop in smoking rates among high school students compared to surrounding communities which kept the age limit at 18.  But from 2010 to 2012, the reverse was true: surrounding communities that kept it at 18 began to see faster declines in teen smoking rates than Needham.  This inconvenient fact was acknowledged buried in the original study (that went up to 2012) used to sing the praises of Tobacco 21, so it was not simply an oversight by the authors.  And according to the publicly available data that can be gleaned from schools in the surrounding communities, by 2014 the pattern reversed entirely, with the neighboring towns seeing larger net declines in teen smoking (59 to 77% drop) than Needham (40% drop) since 2006.  Hardly miraculous.  And by 2016, we see that some of these other towns raised the tobacco age limit to 21, but without seeing any further decrease in teen smoking (in fact, they saw a slight increase from 2014 to 2016).  If that's "success", we'd really hate to see what failure looks like.

So what explains the short-term success in the first few years in Needham?  Well, it could simply be have been a real but short-lived (and hollow) effect of the policy, just as Miron and Tetelbaum (2009) saw with the 21 drinking age versus traffic fatalities in the 1980s, with the effect being fairly small, dissipating after the first year or two before rebounding later, and further limited to the early-adopting states only (while in the later-adopting, coerced states, it actually had a perverse effect, or at best no effect).  But Needham also increased their enforcement on vendors dramatically, and also had at least some other tobacco laws that surrounding communities lacked.  And the percentage of smokers under 18 who bought their own cigarettes from stores also declined in Needham but not in the other neighboring towns.

Thus, it is very likely that the early decline in teen smoking would have been just as large if not larger had they simply kept the age limit at 18 but stepped up enforcement all the same, ceteris paribus.

Indeed, one should note that Woodridge, Illinois saw a similarly large drop in teen smoking in an even shorter timeframe (just two years) from 1989 to 1991 while keeping the smoking age at 18.  Leominster, MA also saw a drop almost as large from 1989 to 1991 as well.  And NYC, who raised their age limit from 18 to 21 (with no grandfather clause) in 2014, did NOT see teen smoking rates drop any faster than in the nation as a whole from 2013 to 2015.  Thus, the most parsimonious explanation is that Needham's (short) success story was primarily (if not entirely) due to increased vendor enforcement interacting with secular trends, and not the raising of the age limit itself.  In any case, it turned out to be a promise built on sand all along, if not a total statistical mirage.

Tobacco 21 laws, just like the ageist abomination that is the 21 drinking age, clearly belong on the trash heap of history.  And this is the final nail in the coffin.

Calling It QUITS

There is a new bipartisan bill in Congress now, called the Quell Underage Inhaling of Toxic Substances (QUITS) Act.  And to be honest, it is a mixed bag overall.  It would:

• Ban flavored e-cigarettes (i.e. vape products) and other flavored tobacco products, including menthol.
• Increase the federal cigarette tax from $1 per pack to $3 per pack.
• Create a tax on e-cigarettes equivalent to $3 per pack.
• Increase annual funding for the CDC's Office of Smoking and Health from $210 million to $500 million.

The first item on the list, the flavor ban as we have noted before, is too broad and largely due to the moral panic around vaping these days.  Throwing out the proverbial baby with the bathwater is likely counterproductive, and slopes are slipperier than they appear.  other items on the list are overall a good idea though.  At least all of these also apply to, and does not ignore, the real elephant in the room:  combustible cigarettes and other combustible tobacco products, which kill over 480,000+ Americans per year, while vaping has killed eight people so far in all of its history, and even then, mostly via black-market THC products rather than legitimate ones.  And while even one such death is one too many, compared to combustible cigarettes, that's essentially a mere rounding error in statistical terms.

Another strength is that it does not raise the age limit for tobacco or vaping products at the federal level.  And that, Twenty-One Debunked is happy about.

So what can be added to the bill to improve it, while also removing or narrowing the flavor ban?  Here are some of our ideas:

• Cap and reduce the maximum allowable nicotine content of vape products down to current European and Israeli levels. 
• In fact, while we're at it, cap and gradually phase down the maximum allowable nicotine content of combustible cigarettes down to a non-addictive level as well.
• Tax vape products in a manner that is directly proportional to nicotine content.
• Enforce better (targeting vendors) the current federal age limit of 18 for both vaping and combustible tobacco products.
• Restrict advertising of vape products, similar to how it is for combustible tobacco products.
• Actually REGULATE the vaping industry, and require quality control testing.
• Crack down on black-market and counterfeit vape products, and root out any bad actors in the legitimate market as well.
• Legalize and regulate cannabis at the federal level, and implement strict quality control standards as well for both cannabis as well as tobacco/nicotine products.
• Require ALL vape products, whether nicotine, THC, CBD, or otherwise, to transparently disclose all ingredients, and immediately ban the use of questionable additives believed to be linked to the outbreak of the mystery vaping illness.

Let's be adult about this, shall we? 

When It Comes To Vaping, Don't Throw Out The Baby With The Bathwater

In the wake of both the mysterious vaping-related lung illness epidemic, and also the recent increase in vaping among young people (something for which Tobacco 21 laws have apparently done NOTHING to stem the tide, by the way) both the federal government and several state and local governments are beginning to crack down on vaping to one degree or another.  Yes, Houston, we have a problem.  But it is important to keep a cool head and not throw out the proverbial baby with the bathwater.

The FDA plans to ban all flavored vape products other than tobacco (yuck!) or unflavored (meh), as is Michigan.  San Francisco, on the other hand, already passed a ban on ALL vape products regardless of flavor.  The state of New York just passed an emergency executive ban on all flavored vape products other than tobacco or menthol, effective October 4th.  And California's governor announced a crackdown on counterfeit vape products, though he lacks the authority to pass any flavor bans without the state legislature passing it.

Going too far with such bans would only increase the very black market that is the most likely cause of the mystery vaping illness (though with that it is mostly black-market THC products, though some appear to have been nicotine only).  At the same time, while vaping can help some adult smokers quit, it's not like there really is any overarching benefit society from nicotine that comes in fruity, candy, or dessert-like flavors either.  It really is a balancing act.

Twenty-One Debunked once grudgingly supported some degree of flavor bans in the past, mainly as an alternative to Tobacco 21 laws, but in light of current events, we no longer support such bans today.

New York's flavor ban--if there must be one at all--is somewhat more reasonable than the ones that don't even allow menthol.  And clearly counterfeit products need to be cracked down upon, and bad actors and questionable additives rooted out at once.  And capping and reducing nicotine levels of vape products down to European and Israeli levels would also make such products less addictive than they are currently.  But anything more stringent than these things would likely do more harm than good.  (That goes for setting the age limit any higher than 18 as well.)

As for cannabis vaping products, the best way to eradicate the sketchy and janky black and gray market products is to fully legalize and regulate cannabis nationwide, period, with an age limit of 18, strict quality control, and reasonable taxes on such products.  And again, crack down on counterfeit products and products with questionable additives.  But that would make too much sense, wouldn’t it?

So let's be adult about this, shall we?

UPDATE:  Looks like Michigan's emergency executive flavor ban contains a loophole that allows flavored nicotine-free e-liquids and pods, and also allows flavorless nicotine packets one can combine with such e-liquids (albeit sold separately).  So this particular ban is actually far more reasonable than meets the eye, while still having the intended effect of making it somewhat harder and less convenient for people under 18 to vape flavored nicotine.  And it will likely keep vape shops open for business for the foreseeable future, while JUUL will still get a swift kick in the margins now that their ready-made pods will be verboten if they have any flavor other than tobacco.

And at the other extreme, on September 24th, Massachusetts Governor Baker has literally banned ALL vape products for four months by an emergency executive action.  And that will just throw gasoline on the fire by dramatically growing the black market. DERP!  Didn't think that one through, did you Charlie?

JUUL Is Circling The Drain

Looks like JUUL Labs just bit off far more than they could ever possibly chew, and they are now choking on it as we speak.  These quislings have asked for a ton of karma for years now, and now they seem to be getting it.  Their share price is in warp-speed decline right now.  As per the famously time-tested Seneca effect, their growth was relatively slow at first, but it looks like their ruin will be very, very rapid indeed.

First, they managed to get a new generation of young people hooked on nicotine with a sleek, deceptively seductive, fruity- and candy-flavored product (with excessively high nicotine levels, and more addictive than conventional cigarettes) and even more deceptive, Big Tobacco-style marketing, all while bragging about how supposedly "woke" they were.  Then they made a deal with the devil himself, Big Tobacco, when they literally SOLD OUT to them.  And then when these cowardly quislings were finally called out on their misdeeds, they threw 18-20 year olds under the bus by supporting the ageist abomination that is Tobacco 21 laws.  They even threw the rest of the vaping industry under the bus as well.  At the end of the day, they are really nobody's friends, never were, and never will be either.

And now with that mysterious vaping-related illness reaching epidemic proportions, albeit most likely driven by black-market products with questionable additives, as well as homebrew concoctions and modified devices (though JUUL still has yet to be exonerated), the moral panic around vaping that JUUL effectively helped to create has reached such a fever pitch that the Trump administration (and several states) are passing or at least considering flavor bans for vape products.  That will be the final kiss of death for JUUL, since most of these proposed bans will only allow tobacco-flavored products (yuck!) or unflavored products (meh), not even menthol or mint.  Even if the ban is later lifted, if (when) it passes they are basically dead and done by that point.

And if that itself doesn't ultimately bankrupt them, the mounting lawsuits against them sure will.

Now a corporate "person" without a country, what ever will they do?  (Plays the world's smallest violin)

Somebody call the coroner quick, JUUL is now circling the drain as we speak.  Let's hope they take their Big Tobacco parent company, Altria (aka Philip Morris) down with them as well.  And no, we will never, ever mourn their loss, not in a million years.

Good riddance! May your name and memory be forever blotted out, JUUL.

UPDATE:  As of September 25, 2019, their CEO, Kevin Burns, was essentially forced to resign, replaced with a Big Tobacco executive from Altria, and they pulled all advertising from the USA.  And the company agreed to accept the flavor ban as well.  And now they are embroiled in a criminal investigation as well.

About That Mysterious Lung Illness Related To Vaping

There have been recent reports of a mysterious lung illness that appears to be linked to vaping.  Fingers are being pointed all over the place right now, since it is still not clear exactly what (let alone which products) are causing it and why.

Here's what we do know so far.  As of the end of August 2019, there have been over 200 possible cases of severe lung illness and/or damage (and even one reported death) in the USA that may be linked to vaping, though the symptoms haven't always followed a consistent pattern.  Not all cases have been confirmed, and it all still needs to be fleshed out and other variables accounted for, but vaping of some sort is the only factor that we know is common to them all.  And it's not just young people either (though many of them are), as even people in their thirties have reportedly also succumbed to it as well.

Many, but by no means all, of the cases involved vape products containing THC (i.e. the primary psychoactive component of cannabis), and virtually all of those had been purchased on the black market (mostly in non-legalization states) based on what we know so far.  And as much as JUUL Labs wants to believe and assert it, this does NOT yet automatically exonerate nicotine-containing vape products such as theirs.  And no one should pretend that it does.

(Separately, there are also three recent reports of seizures thought to be linked to the JUUL brand specifically, presumably due to their very high nicotine content, so they really shouldn't be so smug.)

It is important not to create or fan the flames of a moral panic about vaping in general, as that is likely to be counterproductive.  Much more research is necessary until we know more.  So what advice should be given in the meantime?

• First and foremost, do NOT vape anything that you get from the black market, whether it's THC or otherwise.  They are inherently unregulated by definition, with no quality control, and thus you really don't know what you are getting.
• Especially avoid the pseudo-legitimate sounding (but actually always black market) THC brands "Dank Vapes", "Chronic Carts", and "West Coast Carts".  Avoid them like the plague!  (Ditto for the apparently very bad actor, gray market CBD brand "Diamond CBD" as well.)
• Do your research and due diligence before buying any vaping product on the legitimate market as well.  Google is your friend, but don't believe everything you hear or read.  This is true whether it is nicotine, THC, CBD, "just flavoring", or anything else for that matter.
• Avoid any oil-based vape products when possible, especially for unfamiliar brands.
• Do NOT modify vaping devices or use any homebrew products with vaping devices.
• And last but not least, if you are not currently addicted to nicotine, do NOT vape (or smoke) anything that contains nicotine.  Keep in mind that all JUUL brand products contain high levels of nicotine, as do many other brands as well.

That seems like sensible advice for now.  As for government officials, the best thing they can do right now is regulate the vaping industry better to quash bad actors and improve quality control, cap nicotine levels, and also legalize cannabis nationwide for everyone over 18 (while keeping the taxes low) in order to quash the black market as well.

Let's be adult about this, shall we?

UPDATE:  As of September 5, 2019, researchers seem to be zeroing in on the most likely cause: specific additives found in primarily black market THC vaping oils and cartridges.  Thus far, only one case has been possibly linked to a THC vape product (of undisclosed brand) purchased from a licensed dispensary (in Oregon), which could be a fluke or confounded by other products, but it is possible that even some legitimate products contain such harmful additives.  And while nothing has been ruled out as yet, the aforementioned advice still remains sound:  avoid all black market vape products, don't vape nicotine if you aren't already addicted, and do your research.

As of September 6, the number of possible (not all of which confirmed) cases of the mystery vaping illness has now reached at least 450, including four confirmed deaths and possibly a fifth one as well.  At this rate, we would hate to see what the casualty toll will ultimately climb to by Friday the 13th (next week).  Regulators really need to root out the questionable additives and bad actors, yesterday.

As of September 9, several theories abound as to what exactly is causing this now-epidemic mysterious illness, from questionable additives (such as Vitamin E oil) to black market products to home-made concoctions influenced by YouTube videos to even Chinese tariffs steering vapers towards cheaper and janky products (and this means nicotine too).  Again, it is still under investigation, but the above advice nonetheless remains sound for the time being. 

And for those who are still concerned:

If you currently vape nicotine, DO NOT go back to combustible cigarettes or any other combustible tobacco products!  If you are concerned about vaping, you can always switch to snus, lozenges, or any of the available nicotine replacement therapy products currently on the market (patches, gums, lozenges, and inhalers).  At the very least, stick to the top-shelf stuff.

If you currently vape "just flavoring", be sure that it really IS "just flavoring" (spoiler alert:  it usually is NOT, and all JUUL brand products contain high levels of nicotine).  But really, what's the point of that?

If you currently vape cannabis derivatives (whether it's THC, CBD, or both), and you don't have access to legal and licensed dispensaries where you live and/or you still don't trust the stuff on the shelves there, but you still don’t want to combust (smoke) weed, there are always dry-herb vaporizers out there (remember those?), as well as edibles, capsules, oils, and tinctures for using cannabis products orally.  Or at least stick to the top-shelf stuff for now.  But DO NOT vape, juul, or dab anything from the black market, the street, pop-up shops, or any homemade concoctions.  EVER.