Marijuana Legislation and Electronic Cigarette– or Vaping–Associated Lung Injury

Meghan M. Cirulis, Sean J. Callahan, Scott K. Aberegg
2020 JAMA Network Open  
In JAMA Network Open, Wing et al 1 report an intriguing and insightful analysis of state-level incidences of electronic cigarette (e-cigarette)-or vaping-associated lung injury (EVALI), determined from case rates from the Centers for Disease Control and Prevention and Surveillance, Epidemiology, and End Results estimates of state populations. They found that the incidence of EVALI is lower in states that have legalized recreational marijuana and its active ingredient, tetrahydrocannabinol
more » ... drocannabinol (THC), compared with states where it remains illegal or available only for medicinal uses. This finding withstood adjustment for variation in vaping rates among states. The cross-sectional nature of the analysis and inherent limitations of the available data mean that the ecological fallacy and other sources of confounding may be at play. In part because of its preliminary nature, interesting questions arise from the analysis, answers to which are likely to ultimately be found at the intersection of sociology, public health, and the law. It is illuminating to examine some of these questions through a wide historical lens. One hundred years ago, on January 17, 1920, the Eighteenth Amendment of the US Constitution went into effect, prohibiting the manufacture, sale, or transport of intoxicating liquors. Moral and social sentiments, rather than a concern for public health per se, were the impetus for the amendment. Nonetheless, the desired but imperfectly realized result of Prohibition-curtailment of alcohol consumption-brought welcome salutary effects, some recognized only in retrospect. Rates of liver cirrhosis, 2 psychiatric admissions for alcoholic psychosis, 3 and infant mortality 4 declined, as did arrests for drunkenness and related offenses. 3 Not all secondary effects were positive, however. Bootlegging was rampant and criminal syndicates proliferated, fueling a wave of organized crime. Bootleggers fortified their distillates with methanol to increase apparent potency, causing blindness and death in unwary consumers. 5 They also procured industrial ethanol, exempted from Prohibition and mass produced cheaply, as raw material for alcoholic beverages. In response, at the behest of the US government, industrial ethanol stocks were intentionally adulterated with methanol, benzene, and other poisonous substances to deter their consumption. The resulting concoctions, known as denatured alcohol, were responsible for thousands of deaths during the 14 years that Prohibition was in effect. 5 The history of Prohibition thus serves as a cautionary tale about unintended and unforeseen consequences of legislation regulating substances that affect public health. Nearly 100 years later, in 2012, Colorado became the first of several states to enact legislation serving as a de facto override of a federal ban on marijuana that has been in effect since shortly after the repeal of Prohibition. These laws form the basis of the analysis reported by Wing et al, 1 showing that EVALI rates are lower in states that have legalized recreational marijuana. Is legalizing marijuana somehow protective against EVALI? If so, how does the protective effect come about? Some additional historical background is necessary. e-Cigarettes were first introduced in 2004 and touted as a safer alternative to traditional combustible tobacco products. 6 Marketing initially targeted adult smokers trying to quit, akin to other nicotine delivery methods, such as nicotine gum and transdermal patches. Used in this way, e-cigarettes are viewed by some as a harm-reduction strategy, similar to needle-exchange programs for intravenous drug users. However, in the last decade (coincident with the rise of recreational marijuana legalization), use of e-cigarettes has expanded dramatically to former nonsmokers, notably adolescents and young adults, among whom usage rates have skyrocketed. 6,7 Even if the +
doi:10.1001/jamanetworkopen.2020.2238 pmid:32250430 fatcat:typf7s424zcm5kmow5lgccar7q