Dr Laura Crotty Alexander on the Potential Impacts of the Menthol Cigarette Ban

The e-cigarette or vaping product use–associated lung injury epidemic helped jumpstart the regulation of flavored e-cigarettes, said Laura Crotty Alexander, MD, ATSF.

Laura Crotty Alexander, an associate professor of medicine at the University of California, San Diego, explains progress made in preventing injuries from e-cigarettes and the potential implications of the menthol cigarette ban, at this year's American Thoracic Society (ATS) meeting. Crotty Alexander is also the section chief of pulmonary critical care at the Veterans Affairs San Diego Healthcare System.


What progress has been made in preventing injuries from electronic nicotine and THC delivery systems? Has the spotlight on lung health resulting from COVID-19 helped or hindered progress in this area?

I think that the main driver behind the lower cases of EVALI [e-cigarette or vaping product use–associated lung injury] in 2020 and in 2021 is really from the big spotlight that shone on vaping-induced lung diseases in the latter half of 2019. It really brought into the spotlight the fact that vaping of any device but in particular, vaping of THC, was dangerous. The word got out in 2019. We did see people decreasing their use of e-cigarettes, and those containing THC in particular. But the main driver was when vitamin E acetate was identified as the most likely culprit chemical for causing lung injury. We think it's a combination of manufacturers stopping adding vitamin E acetate to these THC e-liquids, and also people being a little bit more careful about where they're getting their THC e-liquids from. I think that those did contribute to decreased cases of EVALI.

The point about COVID-19 shining a spotlight on lung health, we actually ran a study in collaboration with Eyal Oren, PhD, MS, BA, at San Diego State University. We specifically asked vapers in the time of COVID-19 if they were more worried about their vaping habits, if they were more worried that they might catch COVID-19 or have a more severe form of COVID-19 because of vaping. It was interesting. Vapers were worried about it, but the majority of them didn't think that they would give up vaping, even if they were to get COVID-19. I think that really emphasizes how addictive these devices are. That's why we've been working so hard to try and prevent children and adolescents and young adults from starting to use them. Because we know that once you're addicted to nicotine and even marijuana, that it's incredibly hard to quit, even when you have this life-threatening disease staring down at you.

Can you discuss what implications the ban on menthol cigarettes may have on rates of vape-related diseases?

The other thing that the EVALI epidemic really helped us with was really jumpstarting the regulation of flavored e-cigarettes, which are a tobacco product. I think that was one of the biggest outcomes of that epidemic, that flavored versions of e-cigarettes of some forms were banned nationally and others at city and state levels.

Beyond that, the menthol ban is extremely exciting, because menthol is the much-preferred version of tobacco products used by our Black Americans, our African Americans. The tobacco industry has used menthol to target these populations in particular in this very unfair way. It's very exciting to see this finally coming down the pipe.

It is relevant to e-devices as well because menthol and mint flavorings are some of the most popular flavors, especially for adults but even for children again. While there's been a big push on the regulatory side to get rid of fruity and sweet flavors—which are known to be appealing to children and women, and also again, some minority groups—that's been great to see that targeted. But menthol and mint are also specifically used to make tobacco products appealing. Getting them banned is a big step towards helping prevent people initiate use of e-cigarettes and tobacco and carry on using them.