The past several weeks have seen the breathless reporting of a mysterious new public health crisis: lung injuries. E-cigarettes and vaporizers, which have infiltrated the pockets and backpacks of thousands of children and young adults in the United States, have been linked to 12 deaths and hundreds of illnesses. 

As the number of confirmed cases grows, lawmakers have leaped into action: several states have enacted temporary bans on all sales of flavored e-cigarette products, and the federal Food and Drug Administration is in the process of designing a rule that would permanently ban them. These products, which have fruity or candy flavors like mango or creme brûlée, have been blamed for the massive spike in nicotine use among children and young adults.

However, the question remains if banning flavored e-cigarettes will actually have an impact on the number of cases of lung injury, the two being somewhat disconnected. Over 75% of patients reported using vaping products containing THC, the active compound in marijuana, and 36% of patients used those products exclusively. Many THC vaping products are manufactured and sold illegally. These products are untouched by the “vape bans,” leading many to question their effectiveness in addressing the crisis. 

Separate from the current crisis, vape bans will undoubtedly curb the rise of youth e-cigarette use. Flavored products are a particular draw for young people: 96.1% of youth who have used e-cigarettes began with a flavored product, and 70% list liking the flavor as a reason to continue using them. The 2009 ban on flavored tobacco products was estimated to reduce the probability of cigarette smoking by 17% among adolescents, suggesting that a new ban would have a similar effect.

Intervention in this arena is clearly needed. E-cigarette use among high school students use rose 135% between 2017 and 2019, and over 60% of 10th grade students report that e-cigarettes are easy to acquire. In 2018, 4.9% of middle school students and 20.4% of high school students had used e-cigarettes. Strong evidence suggests that e-cigarette use in childhood dramatically increases the likelihood of smoking tobacco later in life. 

As state-level bans have come online in states like Michigan and Massachusetts, the owners of vape and smoke shops have protested that their businesses will evaporate. Lawsuits have been filed in both of those states by groups of vape shop owners seeking to block the bans, calling them a “death sentence” for their businesses. Complaints are also coming from people who have successfully used flavored e-cigarettes to quit smoking, though the science is mixed on whether e-cigarettes are effective as smoking cessation devices.

THC vaping products are the elephant in the room of a debate that has largely boiled down to the relative merits of flavored e-cigarettes as compared to traditional smoking. As mentioned, they are present in the vast majority of recent lung injury cases, and even in states that regulate the legal sale of THC vapes to protect users from harmful additives, consumers can be confused by the proliferation of counterfeit products and black-market options. Scientists suspect that the toxicity of the products is related to vitamin E acetate and other chemicals that are used to formulate the THC liquid. New York Governor Andrew Cuomo has already subpoenaed three manufacturers of vitamin E thickening agents in an attempt to restrict their manufacture and sale.

Recent highly-publicized busts of illegal THC cartridge distributors reveal that the black market is large and complex, usually operating on a national scale. Police departments are struggling to classify, understand, and file charges for a type of drug trafficking that simply did not used to exist. But would legalization solve the problem?

It is true that legalization presents an opportunity for transparent supply chains and preventing the use of harmful chemicals. However, vitamin E acetate and other additives to THC vaping liquids are not limited to the black market. States like Massachusetts are realizing that their regulatory schemes failed to prevent the legal sale of cartridges with similar chemicals.

The lung injury crisis ought to deflate the ebullient rhetoric of the legal marijuana industry, which portrays marijuana as harmless or medicinal and minimizes negative impacts, but it has not. Panicked conversations are taking place among dispensary customers, but the rare national conversations that manage to go beyond the problem of Juul-ing teenagers still only consider black-market cartridges. 

The $10 billion a year legal marijuana industry has gone largely uninterrogated. The opioid crisis is a relevant cautionary tale. Awareness of a problem with overdoses began in the late 1990s, but it wasn’t until 20 years later that companies began to be effectively prosecuted for their role in supplying the public with opioids. By then, it was too late: over 47,000 Americans died of opioid overdoses in 2017 alone. 

The logic of banning flavored e-cigarette liquid in order to reduce uptake by youth is solid. However, it will not reverse this lung injury crisis. More research is needed to pinpoint the origin(s) of the disease, which remain mysterious. Cracking down on the flow of unregulated bootleg vaporizer products will require coordination at every level of government, and governments must resist the temptation to return to war-on-crime-era tactics that will damage the social progress that has come from the marijuana legalization movement. However, the government’s response will not be complete until it fully examines the role of the legal marijuana industry in popularizing and distributing THC cartridges.