A Public Health Perspective on Vaping, E-Cigarettes and the Acute Lung Injury Outbreak

Health risks associated with vaping and e cigarette products have captured the public’s attention as increases in acute lung injury and illness have been reported. The Centers for Disease Control and Prevention (CDC) have reported 1,080 confirmed and probable cases in 48 states and the U.S. Virgin Islands, eighteen of which have resulted in fatalities. CDC has activated its Emergency Operations Center (EOC) and is working closely with the U.S. Food and Drug Administration (FDA) the nation’s public health system begins an investigation of this outbreak. Iowa has 31 confirmed cases and no deaths to date.

As with any health issue impacting our communities, public health officials help coordinate the response effort, resources and expertise to answer the following questions: What do we know? What can we do? Who can help? 

What do we know about vaping and e-cigarettes?

The term e-cigarettes is used to refer to all electronic smoking and vaping devices, including mods, pods, JUUL, vape-pens, hookah-pens, e-hookahs, e-cigars, e-pipes, personal vaporizers, mods and other rechargeable vaping products. 

The injuries and deaths we’ve seen related to e-cigarette use have come to light due to the public health surveillance system. As providers see, treat and report cases related to this outbreak, they are discovering the extent and severity of the issue. Using the basic science of epidemiology, public health can measure the distribution and determinants of the outbreak and help us understand what’s causing it and who is at increased risk.

The cause of these reported illnesses and deaths is under investigation and is, justifiably, the focus of intense public health resources. However, the context for the current outbreak has been unfolding for more than a decade; the tobacco industry has been recreating its image to develop a new generation of addictive products to attract customers.  

What is the public health surveillance system?

Public health surveillance is the cornerstone of public health practice. Surveillance data are crucially important to inform policy changes, guide new program interventions, sharpen public communications, and help agencies assess research investments.
– Centers for Disease Control and Prevention

A history of e-cigarettes

E-cigarettes entered the U.S. marketplace in 2007, and since 2014, they have been the most commonly used tobacco product among U.S. youth. Use among U.S. middle and high school students increased 900% during 2011-2015, before declining for the first time during 2015-2017.  

However, in 2018 current e-cigarette use increased 78% among high school students and 48% among middle school students leading to a 36% spike in overall tobacco use among youth. That same year, more than 3.6 million U.S. youth, including 1 in 5 high school students and 1 in 20 middle school students used e-cigarettes (U.S. Surgeon General).  Among Iowa 6th, 8th and 11th graders, e-cigarettes are the most used tobacco product and are used by 9 out of 10 tobacco users in these grades (Iowa YouthSurvey 2018). While scientists and the public are well aware of the consequences of tobacco use on lung health, new findings suggest that teenage brains affected by nicotine are especially susceptible to substance abuse, attention disorders and impulse control issues.

The marked increase in youth e-cigarette use in 2018 coincides with Altria’s (the U.S. side of Phillip Morris International’s) major investment in JUUL, the e-cigarette retail giant that dominates the U.S. market. In an effort to combat this, the White House recently placed a ban on the sale and advertisement of all flavored e-cigarettes to lessen the number of teenage users nationwide.

Who is most prone to vaping?

In 2018, 22% of Iowa 11th graders reported using e-cigarettes. Students who expressed feeling nervous all or most of the past 30 days were 50% more likely to use e-cigarettes or conventional tobacco products. (2018 Iowa Youth Survey

60.2% of Iowa adults who use e-cigarettes continue to smoke cigarettes, which is referred to as dual-use (2016 Behavioral Risk Factor Surveillance System)  

Big tobacco’s spending dominance over public health efforts

This year alone, states will collect $27.3 billion from tobacco taxes and from the 1998 Master Settlement Agreement; however, these states will invest just 2.4% on programs to prevent youth from smoking and programs that help current smokers quit. The tobacco industry out-spends public health efforts 14 to 1, investing $9.5 billion annually–more than $1 million every hour–on marketing to addict Americans to their products. 

The 1998 Master Settlement Agreement

The Master Settlement Agreement was a landmark legal settlement between major tobacco companies and 46 states, five U.S. territories, the District of Columbia and five of the largest U.S. Cigarette manufacturers. It included regulations regarding the advertising, marketing, and promotion of cigarettes, and required the tobacco industry to pay billions of dollars annually to the participating states. In addition, the MSA imposed certain restrictions on the sale and marketing of cigarettes by participating cigarette manufacturers.
– The 1998 Master Settlement Agreement: An Overview

Despite the $274.2 million in tobacco revenue that Iowa took in from tobacco tax and the MSA in fiscal year 2019, Iowa invested $4 million on tobacco prevention, a mere 1.5% of the revenue and 13.4% of CDC’s recommended investment for our state.    

For every $1 Iowa spends on tobacco prevention the tobacco industry spends $26.60 on marketing its deadly products.   

The toll of tobacco in Iowa can be measures in 5,100 lost lives, $128 billion in annual health care costs and $816 per household in state and federal tax burden from smoking-caused government expenditures. 

What can be done to fight the e-cigarette epidemic?

Regarding the current outbreak, here is the bottom line per the Iowa Department of Public Health:  

  • While this investigation is ongoing, if you are concerned about these specific health risks, consider refraining from using e-cigarette products. 
  • Regardless of the ongoing investigation, anyone who uses e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer. 
  • Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products. If you use e-cigarette products, monitor yourself for symptoms (e.g., cough, shortness of breath, chest pain) and promptly seek medical attention if you have concerns about your health. IDPH, CDC and FDA will continue to advise and alert the public as more information becomes available.
  • Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you who need help quitting tobacco products, including e-cigarettes, call 1-800-QUIT-NOW or visit Quitline Iowa
    If you are concerned about harmful effects from e-cigarette products, call your local poison control center at 1-800-222-1222. 
    The public is encouraged to submit detailed reports of any unexpected tobacco or e-cigarette-related health or product issues to the FDA via the online Safety Reporting Portal.

Addressing Iowa’s public health tobacco policies

Policymakers have a unique opportunity and obligation to craft evidence-based public health policy to address this situation.  As the research around the risk of e-cigarette use evolves, legislators must act on the best available evidence, and campaigns to raise public awareness of the health risks associated with vaping and e-cigarettes must be prioritized.

Effective tobacco control is often described as a three-legged stool with each of the following policy actions required for the stool to balance: 

  1. Increase the price of tobacco products (including e-cigarettes) through regular and significant tobacco tax increases of at least $1.50 per pack of cigarettes with an equivalent rate on other tobacco products.  A $1.50 increase in the cigarette tax will reduce Iowa’s youth smoking rate by 16.4%, prevent 15,900 kids under 18 from becoming adult smokers, help 20,400 current adult smokers quit, prevent 10,100 smoking-caused deaths and save the state over $754 million in long-term health care costs.  
  2. Strengthen Iowa’s Smokefree Air Act, passed in 2008, which prohibits smoking in almost all public places and enclosed areas within places of employment, as well as some outdoor areas.  Presently this law fails to protect Iowa’s casino workers.  It should be expanded to cover non-tribal casinos and include e-cigarettes.
  3. Fund $30.1 million for evidence-based tobacco prevention and cessation programs per CDC recommendations

These three strategies are fundamental to effective tobacco control and prevention and must be our priority. Additional evidence-based interventions include: 

  • Assurance that any tobacco policy (including Tobacco 21) is based on a strong, comprehensive definition of tobacco products to include all current and known products (cigarettes, cigars, smokeless tobacco, pipes, rolling papers, electronic smoking devices and other related devices) and is broad enough to encompass future products.  This will aid in compliance and enforcement and close industry-supported loopholes to exclude certain products.   
  • Restriction of the sale of all flavored tobacco products to make them less attractive to discourage usage by youth. 
  • Limits to the quantity and location of tobacco retailers. 
  • An increase in tobacco cessation coverage in Medicaid and private insurance plans and increase funding to hard-hitting media campaigns that drive cessation attempts. Several large retailers–including Walmart, Kroger and Walgreen’s–have already begun to either alter requirements surrounding tobacco purchases, or have pledged to stop selling e-cigarette products altogether.


Each of us has a role to play to stem the public health impact of e-cigarette and tobacco use. If you are addicted or are seeking help for someone you love, contact your state’s tobacco cessation quit line. The Iowa Department of Public Health is offering a new program called My Life, My Quit, developed especially for teens who want to quit using tobacco, including e-cigarettes. Users can text or call a toll-free number (855.891.9989) or visit the website for real-time coaching. Teens work with a coach who listens and understands their unique needs, provides personalized support, and helps them build a quit plan to become nicotine-free.

Des Moines University is proud to be a tobacco-free campus. For more information about our Master of Public Health program, visit our website or call 515-271-1400. To schedule an appointment at the Des Moines University Clinic, visit the website or call 515-271-1700.

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