Federal and state authorities quickly took action against non-tobacco vaping flavors after a spate of illnesses related to e-cigarettes, but healthcare providers are concerned about their own role in addressing vaping's dangers.
The push to ban certain vaping products comes in light of an outbreak of lung illnesses and deaths associated with e-cigarettes that had risen to more than 530 cases by Sept. 16, according to the Centers for Disease Control and Prevention. Seven deaths have been confirmed in California, Illinois, Indiana, Kansas, Minnesota and Oregon.
Touted as a less harmful alternative to tobacco, vaping appeared on the scene several years ago but has exploded in popularity due in part to flavors and alternative uses like smoking cannabis, which have attracted many young users.
But public health leaders have recently called for people to temporarily avoid using e-cigarettes until more is known about the cause of the illnesses.
"At this point we need to have a stop until we figure out what's going on," said Dr. Georges Benjamin, executive director of the American Public Health Association.
Benjamin said healthcare providers have a vital role to play in raising public awareness about the potential dangers of vaping. Medical organizations could lobby lawmakers to pass regulations that would make it tougher for children to gain access to vaping products, he said.
In August, the CDC suggested healthcare providers ask patients who report having used e-cigarettes within the last 90 days whether they have had pulmonary illness symptoms. Providers should also get a detailed history of e-cigarette products used by the patient if they may be connected to a pulmonary illness and conduct follow-up evaluations of those treated for a suspected vaping-related illness.
"We are urging physicians to talk with their patients about nicotine and tobacco use as a part of their medical history and in talking about vaping, just give them the facts," said Dr. Patrice Harris, president of the American Medical Association. "It's our responsibility as physicians to go where the evidence leads us."
Some public health experts see similarities between the awareness effort related to e-cigarettes and the anti-tobacco campaign that many credit with decreasing both adult and youth smoking rates.
Warnings on cigarettes and tobacco products have been backed by years of evidence, but it may be more difficult to convey similar messages about the relatively new vaping trend.
A June study published in the Journal of the American Heart Association found results of previous trials comparing e-cigarettes with nicotine replacement therapies were inconclusive because of their small sample size.
There also isn't conclusive evidence about the long-term health risks of the devices.
While the CDC warns that non-smoking children, young adults and pregnant women shouldn't use e-cigarettes, it acknowledges vaping devices could be better than regular cigarettes.
That potential use has prevented public health experts from speaking out against e-cigarettes in the same way they combated tobacco. An anti-vaping campaign would have to address e-cigarettes' potential harms and benefits.
"It underscores the extreme complexity of what we're dealing with today," said Cliff Douglas, vice president for tobacco control at the American Cancer Society.
Douglas stressed the American Cancer Society does not endorse e-cigarettes for smoking cessation, but he recognized they could be an alternative for adult smokers who have exhausted or refused to try other cessation methods.
"If that's what they choose, and they're not going to try any other way, then they should receive support and also be encouraged to stop using those products as soon as they're able, but never to resort to conventional cigarette smoking," Douglas said. "If the result of stopping vaping is that people smoke Marlboros again, then that's a disaster—they're not equivalent."
Cigarette smoking is the leading cause of preventable death in the U.S., responsible for 480,000 deaths annually, according to the CDC.
Nearly 11 million adults in the U.S. use electronic cigarettes, according to a 2018 study in the Annals of Internal Medicine. Only 15% of e-cigarette users are not former cigarette smokers.
A study published in February in the New England Journal of Medicine found vaping was more effective for helping tobacco users quit than nicotine replacement therapy when both products were accompanied by behavioral support.
The spate of vaping-related illnesses may lead regulators to require e-cigarettes undergo clinical trials and studies to score FDA approval as a tobacco cessation device, Douglas said. So far, no e-cigarettes have been submitted for that consideration.
But Gregory Conley, president of the American Vaping Association, said e-cigarette makers like Juul Labs would likely seek FDA approval only if the agency rejected their premarket tobacco application, which allows e-cigarettes to be legally marketed as a tobacco product.
In June, the FDA finalized guidance for e-cigarette manufacturers submitting new tobacco product applications through the premarket tobacco application pathway. They must demonstrate the marketing of their product would be appropriate for the "protection of the public health," and to consider, "the risks and benefits" to the population.
Most large e-cigarette companies would likely apply to enter the market as a modified-risk tobacco product — a tougher and more costly designation — by demonstrating it will benefit the health of the population as a whole, Conley said.
"The tobacco companies that make e-cigs that have money that can afford the application process, they're going for the tobacco route," he said. "There are no indications that any American company is looking at the medicinal route."